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Diseases of the Aorta TABLE 36. Thoracic Aortic lmaging Modalities Modality Advantages Disadvantages Transthoracic Good visualization of aortic rooVproximal Requires experienced operator echocardiography (TTE) ascending aorta Limited visualization of the distal ascending aorta Sensitivity and specificity for identifying proximal and aortic arch and branches of the great vessels aortic dissection of 77%-807o and93%-96o/o, respectively A negative TTE result does not rule out aortic dissection, and other imaging techniques must be No exposure to radiation or contrast dye considered Allows definition of valvular pathology, myocardial Diagnosing intramural hematoma may be function, pericardial disease challenging Bedside diagnosis Transesophageal Superior image quality compared with TTE Requires experienced operator echocardiography (TEE) Excellent visualization of the aorta from its root to lnvasive procedure the descending aorta Diagnosing intramural hematoma may be Sensitivity and specificity for identifying proximal cha llenging aortic dissection of 887o-98% a nd 90/"-957", respectively No exposure to radiation or contrast dye Allows definition of valvular pathology, myocardial function, pericardial disease Bedside diagnosis CT angiography Visualization of entire aorta and side branches Exposes patientto radiation and iodinated contrast dye Sensitivity, 1 00%; specificity, 98o/o-99o/" Rapid imaging M u lti planar reconstruction

TABLE 36. Thoracic Aortic lmaging Modalities Modality Advantages Disadvantages Transthoracic Good visualization of aortic rooVproximal Requires experienced operator echocardiography (TTE) ascending aorta Limited visualization of the distal ascending aorta Sensitivity and specificity for identifying proximal and aortic arch and branches of the great vessels aortic dissection of 77%-807o and93%-96o/o, respectively A negative TTE result does not rule out aortic dissection, and other imaging techniques must be No exposure to radiation or contrast dye considered Allows definition of valvular pathology, myocardial Diagnosing intramural hematoma may be function, pericardial disease challenging Bedside diagnosis Transesophageal Superior image quality compared with TTE Requires experienced operator echocardiography (TEE) Excellent visualization of the aorta from its root to lnvasive procedure the descending aorta Diagnosing intramural hematoma may be Sensitivity and specificity for identifying proximal cha llenging aortic dissection of 887o-98% a nd 90/"-957", respectively No exposure to radiation or contrast dye Allows definition of valvular pathology, myocardial function, pericardial disease Bedside diagnosis CT angiography Visualization of entire aorta and side branches Exposes patientto radiation and iodinated contrast dye Sensitivity, 1 00%; specificity, 98o/o-99o/" Rapid imaging M u lti planar reconstruction Magnetic resonance Visualization of entire aorta and side branches For acute disease, prolonged image acquisition angiography away from acute care area Sensitivity and specificity >98% Contraindicated in patients with implanted No exposure to radiation or iodinated contrast pacemaker or defibril lator dy" Gadolinium contrast dye contraindicated in patients with kidney diseaseu

Magnetic resonance Visualization of entire aorta and side branches For acute disease, prolonged image acquisition angiography away from acute care area Sensitivity and specificity >98% Contraindicated in patients with implanted No exposure to radiation or iodinated contrast pacemaker or defibril lator dy" Gadolinium contrast dye contraindicated in patients with kidney diseaseu Aortography Visualization of aortic lumen, side branches, and Diseases of the aortic wall and thrombus-filled collaterals discrete aortic aneurysms may be missed Provides exact information on aorta size and lnvasive procedure that requires power injection shape and any anomalies within the aorta Requires dye load and may be nephrotoxic Catheter manipulation can worsen dissection Poor ability to diagnose intramural hematoma given a lack of luminal disruption

Aortography Visualization of aortic lumen, side branches, and Diseases of the aortic wall and thrombus-filled collaterals discrete aortic aneurysms may be missed Provides exact information on aorta size and lnvasive procedure that requires power injection shape and any anomalies within the aorta Requires dye load and may be nephrotoxic Catheter manipulation can worsen dissection Poor ability to diagnose intramural hematoma given a lack of luminal disruption gadolinium based contrast agents are likely safe in this population. The safety of group lll gadolinium-based contrast agents in this population is unknown.

Aortography Visualization of aortic lumen, side branches, and Diseases of the aortic wall and thrombus-filled collaterals discrete aortic aneurysms may be missed Provides exact information on aorta size and lnvasive procedure that requires power injection shape and any anomalies within the aorta Requires dye load and may be nephrotoxic Catheter manipulation can worsen dissection Poor ability to diagnose intramural hematoma given a lack of luminal disruption gadolinium based contrast agents are likely safe in this population. The safety of group lll gadolinium-based contrast agents in this population is unknown. Because the leading cause of death in patients with TAA is in diameter. In patients with Marfan syndrome, repeat assess rupture, surveillance and treatment depend on aneurysm size ment should be done 6 months after diagnosis to determine and subsequent rupture risk. The average expansion rate of the rate of aortic enlargement. Thereafter, imaging is recom TAA is 0.1 cm/year but is influenced by patient-specific fac- mended every year for aneurysms measuring 3.5 to 4.4 cm in tors. Expansion rate increases with increasing diameter of the diameter and every 6 months if 4.5 to 5.0 cm. In all patients, aneurysm and is faster during pregnancy, when involving the more frequent imaging is recommended if rapid expansion is ascending aorta, and in patients with either Marfan syndrome documented (>0.5 cm/year) or the aneurysm is approaching or bicuspid aortic valve. Annual aneurysm imaging is recom- the threshold for repair. Aneurysms smaller than 5.0 cm are mended for patients with degenerative conditions of the aortic most often imaged with transthoracic echocardiography, pro root or ascending aorta measuring 3.5 to 4.4 crn in diameter; vided an adequate image can be obtained. Other imaging imaging should be performed every 6 months if 4.5 to 5.4 cm modalities include CT angiography (CTA) and magnetic

Because the leading cause of death in patients with TAA is in diameter. In patients with Marfan syndrome, repeat assess rupture, surveillance and treatment depend on aneurysm size ment should be done 6 months after diagnosis to determine and subsequent rupture risk. The average expansion rate of the rate of aortic enlargement. Thereafter, imaging is recom TAA is 0.1 cm/year but is influenced by patient-specific fac- mended every year for aneurysms measuring 3.5 to 4.4 cm in tors. Expansion rate increases with increasing diameter of the diameter and every 6 months if 4.5 to 5.0 cm. In all patients, aneurysm and is faster during pregnancy, when involving the more frequent imaging is recommended if rapid expansion is ascending aorta, and in patients with either Marfan syndrome documented (>0.5 cm/year) or the aneurysm is approaching or bicuspid aortic valve. Annual aneurysm imaging is recom- the threshold for repair. Aneurysms smaller than 5.0 cm are mended for patients with degenerative conditions of the aortic most often imaged with transthoracic echocardiography, pro root or ascending aorta measuring 3.5 to 4.4 crn in diameter; vided an adequate image can be obtained. Other imaging imaging should be performed every 6 months if 4.5 to 5.4 cm modalities include CT angiography (CTA) and magnetic 100

Diseases of the Aorta overall mortality. Aortic repair should be performed in patients Acute Aortic Syndromes with AAA diameter of 5.5 cm or larger, rapid expansion in The most common and life threatening acute aortic syn- AAA size (>0.5 cm/year), or symptoms resulting from AAA (e.g., abdominal or back pain). In patients with an indication dromes are acute aortic dissection and aortic aneurysm mp ture. Other acute aortic syndromes include aortic intramural for aortic repair, the choice between open surgery and endo hematoma and penetrating atherosclerotic ulcer. vascular aneurysm repair (EVAR) is driven by the location of the AAA and involvement of the renal and mesenteric arteries. Suprarenal and juxtarenal aneurysms most often necessitate Pathophysiology open surgical repair. Patient age, comorbid conditions, and Acute aortic dissection involves tearing of the aortic intima, ability to tolerate open surgical repair determine which proce leading to passage of blood from the true lumen of the aorta dure is performed in patients with an infrarenal AAA. EVAR is into a false lumen (Figure 55). Dissection of the aorta can propagate in an antegrade or retrograde fashion, mainly due to associated with lower short term (30-day) morbidity and mortality but no significant differences in long term mortality. shear forces. Propagation of the dissection can cause cardiac Additionally, EVAR is associated with greater need for repeat intervention and significantly higher rates of endoleak, device Acute aortic dissection failure, and postimplantation syndrome (fever, leukocy,tosis, elevated serum C reactive protein level). These complications necessitate diligent follow up with noninvasive imaging tests (CTA or ultrasonography) to evaluate the stent graft.

overall mortality. Aortic repair should be performed in patients Acute Aortic Syndromes with AAA diameter of 5.5 cm or larger, rapid expansion in The most common and life threatening acute aortic syn- AAA size (>0.5 cm/year), or symptoms resulting from AAA (e.g., abdominal or back pain). In patients with an indication dromes are acute aortic dissection and aortic aneurysm mp ture. Other acute aortic syndromes include aortic intramural for aortic repair, the choice between open surgery and endo hematoma and penetrating atherosclerotic ulcer. vascular aneurysm repair (EVAR) is driven by the location of the AAA and involvement of the renal and mesenteric arteries. Suprarenal and juxtarenal aneurysms most often necessitate Pathophysiology open surgical repair. Patient age, comorbid conditions, and Acute aortic dissection involves tearing of the aortic intima, ability to tolerate open surgical repair determine which proce leading to passage of blood from the true lumen of the aorta dure is performed in patients with an infrarenal AAA. EVAR is into a false lumen (Figure 55). Dissection of the aorta can propagate in an antegrade or retrograde fashion, mainly due to associated with lower short term (30-day) morbidity and mortality but no significant differences in long term mortality. shear forces. Propagation of the dissection can cause cardiac Additionally, EVAR is associated with greater need for repeat intervention and significantly higher rates of endoleak, device Acute aortic dissection failure, and postimplantation syndrome (fever, leukocy,tosis, elevated serum C reactive protein level). These complications necessitate diligent follow up with noninvasive imaging tests (CTA or ultrasonography) to evaluate the stent graft. xEY POtilrt o Risk factors for abdominal aortic aneurysm include male sex, advanced age, smoking, atherosclerosis, hypertension, and family history. o One-time screening for abdominal aortic aneurysm with duplex ultrasonography is recommended in men Acute intramural hematoma aged 65 to 75 years who have smoked at least 100 ciga rettes during their lifetime; selective screening is rec ommended for men in this age group who have never smoked. . Aortic repair should be performed in patients with an abdominal aortic aneurysm (AAA) diameter of 5.5 cm or larger, rapid expansion in AAA size, or symptoms resulting from AAA (abdominal or back pain).

xEY POtilrt o Risk factors for abdominal aortic aneurysm include male sex, advanced age, smoking, atherosclerosis, hypertension, and family history. o One-time screening for abdominal aortic aneurysm with duplex ultrasonography is recommended in men Acute intramural hematoma aged 65 to 75 years who have smoked at least 100 ciga rettes during their lifetime; selective screening is rec ommended for men in this age group who have never smoked. . Aortic repair should be performed in patients with an abdominal aortic aneurysm (AAA) diameter of 5.5 cm or larger, rapid expansion in AAA size, or symptoms resulting from AAA (abdominal or back pain). Penetrating atherosclerotic ulcer Aortic Atheroma Aortic atheromatous plaques (atheromas) commonly occur in patients with evidence of atherosclerosis in other vascular beds. The most frequent complication of aortic atheroma is systemic thromboembolism resulting in transient ischemic attack or stroke. Aortic atheromas greater than 4 mm in diam- eter and those with a mobile component are more likely to be associated with thromboembolism compared with smaller atheromas. Aortic atheromas often are detected incidentally on imag tl G U R E 5 5. Cross-sectional representation of acute aortic syndromes. Acute ing studies. Their presence represents a CAD risk equivalent, aortic dissection: interruption of the intima (b/ue) with creation of an intimal flap and false lumen formation within the media (red). Colorflow by Doppler and patients should be considered for antiplatelet and statin echocardiography or intravenous (lV) contrast by CI is present within the false therapies in addition to other risk factor interventions. lumen in the acute phase. Acute intramural hematoma: crescent-shaped

Penetrating atherosclerotic ulcer Aortic Atheroma Aortic atheromatous plaques (atheromas) commonly occur in patients with evidence of atherosclerosis in other vascular beds. The most frequent complication of aortic atheroma is systemic thromboembolism resulting in transient ischemic attack or stroke. Aortic atheromas greater than 4 mm in diam- eter and those with a mobile component are more likely to be associated with thromboembolism compared with smaller atheromas. Aortic atheromas often are detected incidentally on imag tl G U R E 5 5. Cross-sectional representation of acute aortic syndromes. Acute ing studies. Their presence represents a CAD risk equivalent, aortic dissection: interruption of the intima (b/ue) with creation of an intimal flap and false lumen formation within the media (red). Colorflow by Doppler and patients should be considered for antiplatelet and statin echocardiography or intravenous (lV) contrast by CI is present within the false therapies in addition to other risk factor interventions. lumen in the acute phase. Acute intramural hematoma: crescent-shaped rtY PottI hematoma contained within the media without interruption of the intima (b/ue). No color flow by Doppler echocardiography or lV contrast by CT within the crescent. o Patients with an aortic atheroma should be treated with Penetrating alherosclerotic ulcer: atheroma (yel/ow) with plaque rupture antiplatelet and statin therapies to reduce cardiovascu disrupting intimal integrity; the blood pool is contained within the intima-medial 1ar risk. layer (pseudoaneurysm). Color flow by Doppler echocardiography or lV contrast by CI enters the ulcer crater. 102

Diseases of the Aorta tamponade, acute aortic regurgitation, compromise of arterial penetrating atherosclerotic ulcers are more common in type B side branches (carotid, mesenteric, renal, or iliac arteries), and dissections. underperfusion of organs such as the brain, intestines, or kidneys. Diagnosis and Evaluation Aortic dissections are categorized according to their loca- The diagnosis of an acute aortic syndrome requires a high index tion of origin using the Stanford classification, which describes of suspicion because of its life-threatening complications. Acute fype A dissections as originating within the ascending aorta or aortic dissection classically presents as severe, sudden onset aortic arch and type B dissections as originating distal to the chest or back pain that has a tearing or ripping quality. Other Ieft subclavian artery. Type A dissections require surgical presenting features may include hypertension, syncope, a mur intervention because of risk for rupture and death, whereas mur of aortic regurgitation, and heart failure. Asymmetric blood type B dissections often can be managed initially with medical pressures in the upper extremities, asymmetric pulses, or pulsus stabilization and blood pressure control. paradoxus should raise suspicion for acute aortic dissection. lntramural hematomas result from microtears in the aor Abnormalities may be present on chest radiography (wid tic intima and rupture of the vasa vasorum (Figure 56). ened mediastinum) and ECG (ST-segment depression), but Penetrating atherosclerotic ulcers are caused by erosion of the these findings are not diagnostic. In patients with a high likeli internal elastic membrane of the aorta at the site of atheroscle- hood of acute aortic dissection, diagnostic imaging should not rotic plaque, leading to a blood-filled false space within the be delayed based on results ofchest radiography, ECG, or labo wall of the aorta (Figure 57). Both intramural hematomas and ratory testing.

tamponade, acute aortic regurgitation, compromise of arterial penetrating atherosclerotic ulcers are more common in type B side branches (carotid, mesenteric, renal, or iliac arteries), and dissections. underperfusion of organs such as the brain, intestines, or kidneys. Diagnosis and Evaluation Aortic dissections are categorized according to their loca- The diagnosis of an acute aortic syndrome requires a high index tion of origin using the Stanford classification, which describes of suspicion because of its life-threatening complications. Acute fype A dissections as originating within the ascending aorta or aortic dissection classically presents as severe, sudden onset aortic arch and type B dissections as originating distal to the chest or back pain that has a tearing or ripping quality. Other Ieft subclavian artery. Type A dissections require surgical presenting features may include hypertension, syncope, a mur intervention because of risk for rupture and death, whereas mur of aortic regurgitation, and heart failure. Asymmetric blood type B dissections often can be managed initially with medical pressures in the upper extremities, asymmetric pulses, or pulsus stabilization and blood pressure control. paradoxus should raise suspicion for acute aortic dissection. lntramural hematomas result from microtears in the aor Abnormalities may be present on chest radiography (wid tic intima and rupture of the vasa vasorum (Figure 56). ened mediastinum) and ECG (ST-segment depression), but Penetrating atherosclerotic ulcers are caused by erosion of the these findings are not diagnostic. In patients with a high likeli internal elastic membrane of the aorta at the site of atheroscle- hood of acute aortic dissection, diagnostic imaging should not rotic plaque, leading to a blood-filled false space within the be delayed based on results ofchest radiography, ECG, or labo wall of the aorta (Figure 57). Both intramural hematomas and ratory testing. _l

tamponade, acute aortic regurgitation, compromise of arterial penetrating atherosclerotic ulcers are more common in type B side branches (carotid, mesenteric, renal, or iliac arteries), and dissections. underperfusion of organs such as the brain, intestines, or kidneys. Diagnosis and Evaluation Aortic dissections are categorized according to their loca- The diagnosis of an acute aortic syndrome requires a high index tion of origin using the Stanford classification, which describes of suspicion because of its life-threatening complications. Acute fype A dissections as originating within the ascending aorta or aortic dissection classically presents as severe, sudden onset aortic arch and type B dissections as originating distal to the chest or back pain that has a tearing or ripping quality. Other Ieft subclavian artery. Type A dissections require surgical presenting features may include hypertension, syncope, a mur intervention because of risk for rupture and death, whereas mur of aortic regurgitation, and heart failure. Asymmetric blood type B dissections often can be managed initially with medical pressures in the upper extremities, asymmetric pulses, or pulsus stabilization and blood pressure control. paradoxus should raise suspicion for acute aortic dissection. lntramural hematomas result from microtears in the aor Abnormalities may be present on chest radiography (wid tic intima and rupture of the vasa vasorum (Figure 56). ened mediastinum) and ECG (ST-segment depression), but Penetrating atherosclerotic ulcers are caused by erosion of the these findings are not diagnostic. In patients with a high likeli internal elastic membrane of the aorta at the site of atheroscle- hood of acute aortic dissection, diagnostic imaging should not rotic plaque, leading to a blood-filled false space within the be delayed based on results ofchest radiography, ECG, or labo wall of the aorta (Figure 57). Both intramural hematomas and ratory testing. _l at --_.

tamponade, acute aortic regurgitation, compromise of arterial penetrating atherosclerotic ulcers are more common in type B side branches (carotid, mesenteric, renal, or iliac arteries), and dissections. underperfusion of organs such as the brain, intestines, or kidneys. Diagnosis and Evaluation Aortic dissections are categorized according to their loca- The diagnosis of an acute aortic syndrome requires a high index tion of origin using the Stanford classification, which describes of suspicion because of its life-threatening complications. Acute fype A dissections as originating within the ascending aorta or aortic dissection classically presents as severe, sudden onset aortic arch and type B dissections as originating distal to the chest or back pain that has a tearing or ripping quality. Other Ieft subclavian artery. Type A dissections require surgical presenting features may include hypertension, syncope, a mur intervention because of risk for rupture and death, whereas mur of aortic regurgitation, and heart failure. Asymmetric blood type B dissections often can be managed initially with medical pressures in the upper extremities, asymmetric pulses, or pulsus stabilization and blood pressure control. paradoxus should raise suspicion for acute aortic dissection. lntramural hematomas result from microtears in the aor Abnormalities may be present on chest radiography (wid tic intima and rupture of the vasa vasorum (Figure 56). ened mediastinum) and ECG (ST-segment depression), but Penetrating atherosclerotic ulcers are caused by erosion of the these findings are not diagnostic. In patients with a high likeli internal elastic membrane of the aorta at the site of atheroscle- hood of acute aortic dissection, diagnostic imaging should not rotic plaque, leading to a blood-filled false space within the be delayed based on results ofchest radiography, ECG, or labo wall of the aorta (Figure 57). Both intramural hematomas and ratory testing. _l at --_. tIGURE 56. lntramural hematomademonstratedasalow-attenuationbandof hematoma(aror'vs) intheaorticwall onCTimages Axial imagesatthelevel of theaortic arch(topleft),throughthemid thorax(topmiddle),andatthelevel of thesuperiormesentericarterywithnarrowingoftheaorticlumen(topnght)'0bliquesagittal image throug h the a bdomen reformatted iruge t-h,orgh the thorax (note ba nd a rtifact evident without the use of ECG gating ) (bottorn /eft) Coronal reformatted demonstrates thi length of the hematoma and an incidental infrarenal aortic aneurysm (bottom right)'

tIGURE 56. lntramural hematomademonstratedasalow-attenuationbandof hematoma(aror'vs) intheaorticwall onCTimages Axial imagesatthelevel of theaortic arch(topleft),throughthemid thorax(topmiddle),andatthelevel of thesuperiormesentericarterywithnarrowingoftheaorticlumen(topnght)'0bliquesagittal image throug h the a bdomen reformatted iruge t-h,orgh the thorax (note ba nd a rtifact evident without the use of ECG gating ) (bottorn /eft) Coronal reformatted demonstrates thi length of the hematoma and an incidental infrarenal aortic aneurysm (bottom right)' PubIshed by Ekevier lnc All Iighls le5erued. 103

Diseases of the Aorta portability for an unstable patient and lack of iodinated con- trast. Transthoracic echocardiography often is used initially but is limited by inability to image the distal ascending aorta, transverse aortic arch, and descending aorta. Invasive aortogra- phy rarely is indicated for the diagnosis of acute aortic disease; however, it is performed at the time of endovascular repair or when noninvasive testing is contraindicated or unavailable.

portability for an unstable patient and lack of iodinated con- trast. Transthoracic echocardiography often is used initially but is limited by inability to image the distal ascending aorta, transverse aortic arch, and descending aorta. Invasive aortogra- phy rarely is indicated for the diagnosis of acute aortic disease; however, it is performed at the time of endovascular repair or when noninvasive testing is contraindicated or unavailable. Treatment Patients with acute aortic dissection without evidence of car diogenic shock should be treated with medical therapy to lower heart rate and blood pressure. Current guidelines rec- ommend reducing systolic blood pressure to 120 mm Hg or less in the first hour. Intravenous p-blockers are first-line treatment. For hypertension that does not respond adequately to p blocker therapy, an intravenous vasodilator (e.g., nitro- pmsside, nicardipine) should be administered. Pain control is :

Treatment Patients with acute aortic dissection without evidence of car diogenic shock should be treated with medical therapy to lower heart rate and blood pressure. Current guidelines rec- ommend reducing systolic blood pressure to 120 mm Hg or less in the first hour. Intravenous p-blockers are first-line treatment. For hypertension that does not respond adequately to p blocker therapy, an intravenous vasodilator (e.g., nitro- pmsside, nicardipine) should be administered. Pain control is : often necessary and is best accomplished with intravenous opioids. An algorithm for the management of acute ascending aortic dissection is shown in Figure 58. Emergency surgery should be considered for acute aortic dissection complicated by cardiogenic shock, type A dissection, and type A intramural :

often necessary and is best accomplished with intravenous opioids. An algorithm for the management of acute ascending aortic dissection is shown in Figure 58. Emergency surgery should be considered for acute aortic dissection complicated by cardiogenic shock, type A dissection, and type A intramural : hematoma, given the very high mortality rate associated with these conditions. Decisions regarding concomitant aortic arch j reconstmction, aortic valve replacement, branch vessel repair, and/or coronary artery bypass graft surgery or coronary artery : reimplantation depend on the anatomy of the dissection, involvement of the aortic valve or branch vessels. and other patient characteristics. Patients with uncomplicated type B aortic syndromes may be treated with medical therapy initially. Compared with medical therapy, TEVAR is associated with similar clinical outcomes (overall survival) but improved aortic specific death rates and disease progression measures at 5 years. Patients FIGU R E 5 7. Penetrating atherosclerotic ulcer of the proximal descending with type B dissection and refractory chest/back pain or thoracic aorta. Axial CT images at the level of the aortopulmonary window (top) and hypertension, rapid aortic expansion, or organ malperfusion at the level of the left pulmonary artery (bottom) demonstrate a small penetrating ulcer (arow) that extends beyond the expected confines of the aortic lu men with should undergo aortic repair. adjacent i ntramura I hematoma both at the level of the u lcer itself and that extends a In patients with an aortic intramural hematoma or pen few centimeters caudally in the wall of the descending thoracic aorta. U = penetrating etrating atherosclerotic ulcer, treatment choices depend on the u lcer. location of the hematoma or ulcer, progression to aortic dis Reproduced with permission from Hiratzka LF, Bakris GL, Beckman JA, et al; American Coilege of Cardiology section, and evidence of aortic enlargement. Immediate aortic Foundation/American Heart Association Task Force on Practice Guidelines.2010 ACCF/AHA/AATS/ACR/ASA/SCIV SCAI/SlR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A report repair is indicated in patients with a type A aortic intramural of the American College of Cardiology Foundation/American Heart Association Task Force 0n Practice Guidelines, American Associati0n f0rTh0racic Surgery, American College of Radiol0gy, American Str0ke Association, Society hematoma or penetrating atherosclerotic ulcer and in those of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and lnteruentions, Society 0f l0teruentional Radiology,Society ofThoracic Surgeons, and Society forVascular Medicine. J Am Coll Cardiol. with enlargement or progression of disease after detection. 2010;55:e27-e129.IPMID:20359588]doi:10.1016/j.jaa.2010.02.015.@20l0AmericanCollegeofCardiology Foundation and the American HeartAss0ciati0n, lnc. Published by Elsevier lnc. All riqhts reserued. f,EY POIIIIT o Acute aortic dissection classically presents with the CTA, MRA, and transesophageal echocardiography have sudden onset ofsevere tearing pain in the chest, back, similar sensitivity and speciflcity in diagnosing acute thoracic or abdomen. aortic disease; however, CTA is the imagrng modality of choice o Clinical examination findings that increase the index of because it provides important information for procedural plan- suspicion for an acute aortic syndrome include pulsus ning and has widespread availability. Compared with CTA and paradoxus, asymmetric blood pressures in the upper MRA, the primary advantages of transesophageal echocardiog extremities.andasymmetricpulses.,^ontinued) raphy in patients suspected of having aortic dissection include

hematoma, given the very high mortality rate associated with these conditions. Decisions regarding concomitant aortic arch j reconstmction, aortic valve replacement, branch vessel repair, and/or coronary artery bypass graft surgery or coronary artery : reimplantation depend on the anatomy of the dissection, involvement of the aortic valve or branch vessels. and other patient characteristics. Patients with uncomplicated type B aortic syndromes may be treated with medical therapy initially. Compared with medical therapy, TEVAR is associated with similar clinical outcomes (overall survival) but improved aortic specific death rates and disease progression measures at 5 years. Patients FIGU R E 5 7. Penetrating atherosclerotic ulcer of the proximal descending with type B dissection and refractory chest/back pain or thoracic aorta. Axial CT images at the level of the aortopulmonary window (top) and hypertension, rapid aortic expansion, or organ malperfusion at the level of the left pulmonary artery (bottom) demonstrate a small penetrating ulcer (arow) that extends beyond the expected confines of the aortic lu men with should undergo aortic repair. adjacent i ntramura I hematoma both at the level of the u lcer itself and that extends a In patients with an aortic intramural hematoma or pen few centimeters caudally in the wall of the descending thoracic aorta. U = penetrating etrating atherosclerotic ulcer, treatment choices depend on the u lcer. location of the hematoma or ulcer, progression to aortic dis Reproduced with permission from Hiratzka LF, Bakris GL, Beckman JA, et al; American Coilege of Cardiology section, and evidence of aortic enlargement. Immediate aortic Foundation/American Heart Association Task Force on Practice Guidelines.2010 ACCF/AHA/AATS/ACR/ASA/SCIV SCAI/SlR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A report repair is indicated in patients with a type A aortic intramural of the American College of Cardiology Foundation/American Heart Association Task Force 0n Practice Guidelines, American Associati0n f0rTh0racic Surgery, American College of Radiol0gy, American Str0ke Association, Society hematoma or penetrating atherosclerotic ulcer and in those of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and lnteruentions, Society 0f l0teruentional Radiology,Society ofThoracic Surgeons, and Society forVascular Medicine. J Am Coll Cardiol. with enlargement or progression of disease after detection. 2010;55:e27-e129.IPMID:20359588]doi:10.1016/j.jaa.2010.02.015.@20l0AmericanCollegeofCardiology Foundation and the American HeartAss0ciati0n, lnc. Published by Elsevier lnc. All riqhts reserued. f,EY POIIIIT o Acute aortic dissection classically presents with the CTA, MRA, and transesophageal echocardiography have sudden onset ofsevere tearing pain in the chest, back, similar sensitivity and speciflcity in diagnosing acute thoracic or abdomen. aortic disease; however, CTA is the imagrng modality of choice o Clinical examination findings that increase the index of because it provides important information for procedural plan- suspicion for an acute aortic syndrome include pulsus ning and has widespread availability. Compared with CTA and paradoxus, asymmetric blood pressures in the upper MRA, the primary advantages of transesophageal echocardiog extremities.andasymmetricpulses.,^ontinued) raphy in patients suspected of having aortic dissection include 104 :

Diseases of the Aorta Ascending aortic dissection by imaging study STEP 1 Determine ls patient a suitable No Begin medical suitability for candidate for surgery? management surgery Yes STEP 2 Determine ls patient stabl€ enough stability for to allow preoperative testing? preoperative testing Yes STEP 3 Assess need for Yes Determine preoperative coronary Age >40 years? likelihood of angiography coexistent CAD . Known CAD? No o Significant risk factors for CAD? Yes Significant CAD by No angiography? Plan for CABG if appropriate" at time of AoD repair STEP 4

. Known CAD? No o Significant risk factors for CAD? Yes Significant CAD by No angiography? Plan for CABG if appropriate" at time of AoD repair STEP 4 lntraoperative Urgent operative management evaluation of aortic valve lntraoperative assessment of aortic valve by TEE: Aortic regurgitation? or Dissection of aortic sinuses? STEP 5 Yes No Surgical Graft replacement Graft replacement interuention of ascending aorta of ascending aorta +/- aortic arch +/- aortic arch and repair/replacement of aortic valve or aortic root FIGURE 58.Acutesurgical managementpathwayforAoD.AoD=aorticdissection; CABG=coronaryarterybypassgrafting; CAD=coronaryarterydisease;TEE=transesophageal echocard iog ra phy. JAmCollCardiol.2009;53:53053.IPMID:19195618]d0i:10.1016/jjarc.2008.10.005

STEP 5 Yes No Surgical Graft replacement Graft replacement interuention of ascending aorta of ascending aorta +/- aortic arch +/- aortic arch and repair/replacement of aortic valve or aortic root FIGURE 58.Acutesurgical managementpathwayforAoD.AoD=aorticdissection; CABG=coronaryarterybypassgrafting; CAD=coronaryarterydisease;TEE=transesophageal echocard iog ra phy. JAmCollCardiol.2009;53:53053.IPMID:19195618]d0i:10.1016/jjarc.2008.10.005 Published by Elsevier lnc. All riqhts reserued. 105