aortic catastrophes: big red causing big problems!€¦ · andrew d. perron md, facep. professor...
TRANSCRIPT
A N D R E W D . P E R R O N M D , F A C E PP R O F E S S O R A N D R E S I D E N C Y P R O G R A M D I R E C T O R
D E P T O F E M E R G E N C Y M E D I C I N EM A I N E M E D I C A L C E N T E R
P O R T L A N D , M E
Aortic Catastrophes: Big Red Causing Big Problems!
Disclosures
None No $$, no devices,
no patents No LLCs No family “in the
business” None !
Where are we going?
Going to Cover Spontaneous dissection AAA Traumatic dissection
Caveat: There is NOT a lot NEW in the world ofaortic emergencies…but sometimes it is nice togo over this stuff to be sure we are all on the samepage.
AorticDissection
“A man was seized with pain of the right arm and soon after the left. He was ordered to think seriously and piously of his departure from this mortal life, which was very near at hand and inevitable.”J.B. Morgagni, 1761.
“There is no diagnosis more conducive to clinical humility than dissection of the aorta.”Sir William Osler, 1900.
ED Management
Job #1 Job #2
Find The Disease
HaltProgression
Correct definitive care
Job #3
Here’s The Problem…
We Are Not Very Good At Making The Diagnosis
Giving The Wrong Therapy Hurts Patients
We Can’t CT Every Patient
With Chest Pain
Initial diagnosis correct 15-50%Diagnosis >24 hours in 40%
Klompas M. JAMA 2002.
Type A: involves the ascending aortaType B: does not involve the ascending aorta
“Acute” if ≤14 days of symptoms
Aortic Dissection: Risk Factors
Common: Hypertension Cocaine Trauma Pregnancy
Iatrogenic Heart surgery AVR Catheterization
Congenital Aortic coarctation Bicuspid valve Marfan Ehlers-Danlos Turner
H A G A N P G . J A M A 2 0 0 0 , 2 8 3 : 8 9 7 .
“The International Registry of Acute Aortic Dissection [IRAD]:
New Insight Into An Old Disease.”
N = 46412 Centers
IRAD: Demographics
Hagan PG. JAMA 2000.
Male 65.3%Mean age* 63 yearsType A dissection 62.3%Hypertension 72.1%
*Type B older, Marfans mean age 36 years
IRAD: Clinical Manifestations
Pain reported in 95.5%:
Hagan PG. JAMA 2000.
Chest pain 72.7%Anterior chest pain 60.9%Back pain 53.2%Abdominal pain 29.6%
IRAD: Clinical Manifestations
Quality of pain:
Hagan PG. JAMA 2000.
Abrupt onset 84.4%‘Worst pain ever’ 90.6%Sharp 64.4%Tearing or ripping 50.6%Radiating 28.3%Migratory 16.6%
IRAD: Syncope
Syncope in 9.4% More common with Type A dissection Higher risk of tamponade & stroke
Hagan PG. JAMA 2000.
Mortality
History of Syncope 34%Overall 28%
K L O M P A S M . J A M A 2 0 0 2 , 2 8 7 : 2 2 6 2 .
“Does This Patient Have AnAcute Thoracic Aortic
Dissection?”
N = 184821 Studies
How Good Is Our Assessment?
Review of the accuracy of the history, examination, and chest X-ray in the diagnosis of acute aortic dissection.
Klompas M. JAMA 2002.
Studies enrolling patients with the disease, or with a high likelihood of the disease
overestimate sensitivity.
Klompas M. JAMA 2002.
Most patients have severe pain of sudden onset
[+] LR 2.6
The absence of sudden onset pain lowers likelihood
[-] LR 0.3
The presence of “tearing” or “ripping” pain increases likelihood
[+] LR 1.2-10.8
The presence of pain that migratesincreases likelihood
[+] LR 1.1-7.6
Clinical History
Klompas M. JAMA 2002.
The presence of a pulse deficitincreases likelihood
[+] LR 5.7
The presence of focalneurological deficit increases likelihood
[+] LR 6.6-33.0
The presence or absence of a diastolic murmur is not useful
[+] LR 1.4[-] LR 0.9
Physical Examination
Klompas M. JAMA 2002.
The presence of normal aortic contour & normal mediastinum on CXR decreases likelihood
[-] LR 0.3
Caveat: There is no single radiographic finding that accurately predicts the presence of aortic
dissection.
Chest Radiography
IRAD: Chest X-Ray
Findings:
Hagan PG. JAMA 2000.
Wide mediastinum 66.1%Abnormal aortic contour 49.6%Pleural effusion 19.2%Wall Ca++ displacement 14.1%Normal CXR 12.4%
Egg Shell Sign
Aortic Dissection: D-Dimer?
About a dozen studies between 2004-2015 None large, randomized In an all-comer population where incidence = 5%
(pre-test prob), negative d-dimer would miss 1:1000 patients with the disease, but would generate 440 false positives for every 1,000 patients
ACEP clinical policy says “no”.
Good summary: Spiegel R “D-Dimer for aortic dissection: the evidence.Https://first10em.com/d-dimer-aortic-dissection. Accessed 1/25/20
Aortic Dissection: CT Angio
Study of choice in the stable patient
High sensitivity
Identifies alternative diagnoses
Aortic Dissection: Bedside US
Nice option when the patient can’t move
More sensitive for Type A dissections
ED Management
ED treatment goals: Control dp/dt Reduce blood pressure [<120systolic] Prevent reflex tachycardia Slow the propagation of the dissection
American College of CardiologyAmerican Heart Association
Dissection: Treatment
Type A = Open surgery preferred (at least for now) Even Europe (where they have 3-branch stents and a longer
track record ) do not treat Type A’s with EVAR
Type B = Endovascular (if possible) Lower morbidity Lower mortality
Abdominal Aortic Aneurysm
Essential Demographics
Most common aneurysm Genetics important Smoking cessation the most important
modifiable risk
Greenhalgh R. NEJM 2008.
1.7% of ♀ >65 y/o 5% of ♂ >65 y/o
Essential Demographics
Aortic Rupture: 15,000 death each year Risk significant when >5.5 cm Outcomes:
25% Make it to the hospital10% Make it to the OR5% Make in out of the OR
In Plain English
ElectiveRepair
Repair AfterRupture
95% Survival 5% Survival
Anatomic Considerations
95% are infrarenal
Left of midline
Retroperitoneal
Clinical Manifestations
Classic Triad Abdominal and/or flank pain Hypotension A palpable pulsatile massOnly present 30% of the time!
“Abdominal Palpation for the Diagnosis of Abdominal Aortic
Aneurysm.”
Evidence-Based Emergency MedicineCarpenter CR. Ann Emerg Med 2005, 45;556.
Abdominal Palpation
Methods:Studies after 1966 with >10 patients
We will only look at prospective studies…
Carpenter CR. Ann Emerg Med 2005.
“Positive” Aorta palpable “Negative” Aorta not palpable
Abdominal Palpation
Diameter Sensitivity [+] LR [-] LR3 to 3.9 cm 29% 1.2 0.724 to 4.9 cm 50% 15.6 0.51>5.0 cm 76%
N=2,955, 148 AAA’s detected
Carpenter CR. Ann Emerg Med 2005.
“Helpful if you feel it. Not helpful if you don’t.”
Diagnostic Essentials
Liberal use of ED ultrasound Sensitivity 100% Specificity 98%
Evolving paradigm for CT Early consultation essential Know when to transfer immediately
ED Management Essentials
Things To Do:
Start 2 large-bore IV’s ECG, T&C, CBC, CMP, PT/INR Resuscitate to “BP >85 and talking” Based on animal data… more aggressive resuscitation is
associated with more hemorrhage and increased mortality
Endovascular Repair
First performed in 1991 Less Morbidity / Mortality CT needed Per our high volume operators: “CT Scan so rapid now and
so helpful would be very rare to not be able to get a CT, if they can’t make it to CT they are probably destined to not make it. Usually can get CT quicker than OR can be ready to start.
In theory can size graft off angio in OR but this usually goes very poorly.
EVAR In Rupture
EVAR OpenMortality [all] 5% 28%Mortality [unstable] 14% 56%
Protocol-driven endovascular repair in 126 patients with aortic rupture.
Moore R. J Vasc Surg 2008.
Endovascular Repair
Technical implications: Length to aneurysm neck from renals Shape & angulation of aneurysm neck Diameter & contour of the iliac arteries
Stent eligibility ranges from 15%-50%
Aortic Trauma[TAD]
Chest Radiography In TAD
Wide mediastinum 221 85%Indistinct aortic knob 63 24%Left pleural effusion 49 19%Apical cap 49 19%Tracheal deviation 32 12%NGT deviation 29 11%Bronchus deviation 12 5%Normal chest X-ray 19 7%
Fabian T. J Trauma 1997.
N = 249
Normal BAI
Normal BAI
Helical CT In TAD
Author Total TAD Sensitivity NPV
FabianJ Trauma 98
494 71 100% 100%
MirvisJ Trauma 98
1,104 24 100% 100%
Collier BAJEM 02
232 11 100% 100%
DyerJ Trauma 02
1,338 30 100% 100%
1
43
2
TEE In TAD
Advantages Disadvantages
Portability [ED, OR, ICU] Operator-dependent
Speed of performance Airway protection
Easily repeatable Blind spot
Cardiac assessment Arch vessel problem
No contrast required
TEE In TAD
Meta- analysis [n=724]:
Sensitivity range 56%-99%*
Specificity range 89%-99%*
Combined area under ROC curve 95%
*Performance highest in studies with n ≥ 70
Cinella G. J Trauma 2004.
Life threatening hemorrhage?Operative CNS mass lesion?
StabilizeBP Control
Repair Aorta
Yes No
LaparotomyCraniotomy
Blood Pressure Control
Blood pressure and heart rate control now considered the “standard”…unless paired with brain injury or spinal cord injury.
“That is a tough one. We would aim for normal pressure…not too high not too low. Would depend a little on grade of aortic injury. Would have to individualize based on severity type of neurologic injury and severity of aortic injury”
Endovascular Repair
Prospective, 18-center study Not randomized [operator choice]
Outcome Measures: Mortality Complications Length of stay [LOS]
AAST. J Trauma 2008.
N = 196
125 [65%]Stent
68 [35%]Open
AAST. J Trauma 2008.
MortalityStent Graft Repair* 7.2%Open Repair 23.5%
*Fewer complications & ventilator days, shorter ICU LOS
Questions / Discussion?