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Diseases of Thoracic Aorta1

.. ' ,Basic Anatomy of Aorta

Aortic part Important structures Clinical featuresBranches Related Structures

Aortic root Coronary A. Aortic valve MI(LVOT- Pericardia! space AR, CHFSTJ) Pericardial TamoonadeAscending aorta None Pericardial space Pericardial Tamponade(STJ - SVC SVC syndromeInnominate A.)Aortic arch Innominate A. Lt. RLN Stroke(Innominate A. - Lt. CCA Lt. Phrenic N. Horsenessdistal to Lt. SCA) Lt. SCADescending aorta Branches to Pleural space Paraplegia(distal to Lt. SCA - thoracic organs Bronchus HemothoraxDiaphram) Big intercostal Esophagus Hemoptysis

branch to anterior Lung UGIHsoinal AJT8-1 I)

Abdominal aorta Celiac A. Abdominal Renal failure(Diaphram - SMA organs Bowel ischemiaAortic bifurcation) Renal A. Limb arterial occlusion

IMAIliac A.

Aortic diameter (cm.)

Aorta

AscendinDescendinAbdominal

Normal

3.02.5

1.8-2.0

Aneurysm1.5 times of normal

4.53.75-4.03.0

A ortic wall

Laver Prooertv DiseaseTunica intima Single endothelial cell layer Artherosclerosis

Prevent thrombosisProvide factors for manv processes

Tunica media Thickest layer with fibroblast, Medial wall degenerationcollagen, and elastin Cystic medial necrosisProvide strength Hereditory connective

tissue diseasesTunica adventitia Loose fibrous-connective tissue Vasculitis

Vasa vasorum

Aortic imaging

Basic imaging - CXR nl1lillJn'lu~".ifujj aortic disease

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Advanta esRa id, Available, Chea

Blurrin of aortic knobA ical caHemothorax/effusionRt. Shift of MediastinumAdvanced imaging

Disadvanta esCXR rna be normal in 10-15% of disease

1m ortance>8cm width of mediastinum at carina levelBlood in mediastinum / aortic enlargementMost reliable si n for aortic diseaseBlood surroundin aortaBlood in soft tissue above a ical leuraBlood in leural s aceMass/ ressure effect from aorta/blood

Imaging Advantages Disadvantages CommentCT angiogram Rapid, available Renal contrast toxicity Most appropriate

Skill not need in ThailandHigh sensitivitv

TEE Rapid Skill/personnel need Increasing role inNo contrast developed countriesReal-time/mobileHiQh sens/soec

MRA High specificity Not availableNo renal toxicity Slow, time need

Personnel needAngiography Definite Not available Now used in aortic

Gold standard Renal contrast toxicitv intervention

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Diseases of tlwracic aorta

Diseases Etiology Clinical Indication for PreoperativelMedical',:. !\ findinl!s Sx. Rx.

Traumatic Blunt, Mostly- Immediate Sx. Keep Pt. stable (BPsaortic injury decelerated, hypovolemic 90) before further(Aortic chest injury shock that Urgent if investigationtransection) stable after -Other severe

I.Proximal resuscitation injuries No over resuscitationdescending aorta -Presented> I2.Distal Few -ArresU wk after injury 151 B blocker (IV)ascending aorta Chest pain 2nd Ca blocker (IV) or

NTPIntima>media> Associatedadventitia>pleura with multiple

injuries

Acute aortic Causes: Acute severe Type A- ICU admission anddissection I.Medial wall chest pain emergency Sx. monitoring

degeneration (DDx. MI)(Old age, HT, Type B- Antihypertensive Rx.smoking) Clinical medical Rx 1st Anti-impulse Rx -2.Connective findings based unless B blockertissue diseases on affected complication 2nd Ca blocker or NTP(Marfan, Turner) aortic branches develop3.Atheroscerosis & surrounding

structuresPathology-intimal tear Malperfusion-intimal flap syndrome-true&false when brancheslumen tear off or

compressedStanfordclassificationA-tear starts atascending aortaB-tear starts atdescending aorta

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Diseases. Etiology. Clinical Indication for Sx. Preoperative/Medicalfindinl!s Rx.

Thoracic Major causes: Chest pain Symptoma!ic Optimization ofaortic Same as underlying diseases:aneurysm dissection Depend on Asymptoma'tic Coronary, renal,

structures that -Ascending pulmonary, neurologicMinor causes: affected aorta>5-5.5 cm-Post-trauma -Descending 1st B blocker-infection Ascending aorta>6-6.5 cm 2nd Ca blocker, NTP-arteritis 40-50% -enlargement>-post surgical Descending 0,5cm/6months

30-40%Morphology: Arch 10% Surgical-True(fusiform) complication-false(saccular) -Mortality 8-10%-Chronic -Stroke 2-8%dissection -paraplegia 1-3%

Treatment modality

Modality Observation Surgery Endovascnlar Rx.(TEVAR)

Principle FlU size of aorta Replace all Percutaneousl smallAntihypertensive Rx. diseases with incisional approachSmoking cessation grafts

Intraluminal placementReattachment of of aortic stent acrossimportant aortic disease segmentbranches

Malperfusioncorrection

Indication PI. unwilling/unsuitable v v v Traumatic transection~~m7H'\ll~91Ufor Sx.Small, asymptomatic Mid-descending aorticdiseases aneurysm

Pt.unwiIling/unsuitablefor open Sx.

Advantage No risk of Sx. Complete repair Decreased risk of Sx.(mortality)

Disadvantage Unpredictable course of Risk of morbidity Risk of stroke-open Sxdisease & mortality New modality/long-

term FlU unknown

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Other aortic diseases

Intramural hematoma (IMH)

Penetrating aortic ulcer(PAU)

Treatment indication as same as acute dissection

(type A-surgery, type B-medical Rx.)

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