DISSECAZIONE E

ANEURISMA AORTICO
In order to diagnose by means of TTE , the diameter of the
aorta has to be determined at different levels using multiple
views . Using parasternal axis the measument include the
aortic annulus,
the sinuses , the sino-tubular junction and the first part of
ascending aorta .
The parasteral short-axis view can be used to analyse teh
opening and closing movements of the aortic cusps and can
ientify the presence of an aortic bicuspid valve which is often
associated
With dilation of the proximal ascending aorta .

The aortic arch is visualized using the suprasternal approach :

TEE however is often required .
Right parasternal lonf axis right lateral decubitus allows
observation of a more extensive tract of descending aorta .
Dilation of descending aorta may also be visualized in the
parasternal
long axis view as a circular image behind the left atrium .
1, valve annulus; 2, aortic sinuses; 3, sinotubular
junction; 4, proximal ascending aorta.

21- 34 mm
12- 23 mm/m2

17- 34
mm

21- 34 mm
14- 26 12- 23 mm/m2
mm
Aortic diameter changes
related to body surface area (BSA)
for the four different regions
The term aortic aneurysm refers to a pathological dilatation of the normal
aortic lumen involving one or several segments. One useful criterion defines
aortic aneurysm as a permanent localized dilatation of the aorta having a
diameter at least 1.5 times that of the expected normal diameter of that given
aortic segment, although no definition is universally accepted. Aneurysms are
usually described in terms of their location, size, morphological appearance,
and origin.
 DISSEZIONE AORTICA
Epidemiologia
Incidenza di dissezione aortica in aumento,
attualmente 2 casi/100000/anno
Studio autoptico italiano (36671 autopsie)
Da 1.3 casi/1000 autopsie (1947-1952) a
19.2 casi/1000 autopsie (1977-1982)
Incidenza di rottura 75%
 DISSEZIONE AORTICA
Epidemiologia
La dissezione aortica pi frequente negli uomini che nelle donne (2:1
5:1)
> Incidenza nella V decade
La dissezione prima dei 40 anni interessa principalmente pazienti con
sindrome di Marfan e pu colpire bambini e infanti
La dissezione ad origine distale alla succlavia sinistra pi frequente
delle forme prossimali nei pazienti pi anzianim con una maggiore
incidenza fra 60 e 70 anni
Il rapporto uomoni/donne nelle forme I e II 2:1, 3:1 nel tipo III.
Lincidenza di ipertensione considerevolmente > nei tipo I e II (80%)
rispetto al tipo III (50%)
SOPRAVVIVENZA TIPO B

SOPRAVVIVENZA TIPO A
 DISSEZIONE AORTICA
Definizione
La dissezione aortica acuta un evento
improvviso nel quale il sangue
abbandona il canale aortico normale
attraverso un preciso punto di rottura
intimale e rapidamente disseca la parte
pi interna dello strato esterno della
media. Per convenzione si considerano
acuti i pazienti con dissezione da non pi
di 14 giorni.
J.W. Kirklin &
B.G. Barrat Boyes , CARDIAC SURGERY
DISSEZIONE AORTICA
Fisiopatologia

Nelle grandi arterie le fibre

elastiche si uniscono a
formare lamelle che si
alternano con gli strati di
fibre muscolari; queste
lamelle sono unite luna
allaltra da fibre elastiche
che attraversano I fasci
mscolari, e sono connesse con
le membrane fenestrate dello
strato pi interno
 DISSEZIONE AORTICA
Fisiopatologia
La parete aortica costituita da intima, media e
avventizia
La media rappresenta la componente pi robusta
ed spessa mediamente 1.2 mm (aorta
ascendente) ed lo strato pi colpito dalla
dissezione
La media composta di fibre elastiche e collagene
(ciascuna 20-30% del la parete)
Le cellule muscolari lisce rappresentano il 5% e
producono tutti i costituenti della media
 DISSEZIONE AORTICA
Fisiopatologia
Le lamine elastiche sono lamelle concentriche
fenestrate
Le fibre di interconnessione tengono gli strati uniti
fra loro
Le microfibrille contengono la glicoproteina fibrillina
e costituiscono un importante costituente della
media
Le microfibille costituiscono unimpalcatura per la
deposizione dellelastina e diventano
completamente ricoperte di elastina per produrre
gli anelli concentrici della media
TYPE A
AORTIC
DISSECTION

tear location

true lumen

false lumen
 DISSEZIONE AORTICA
Presentazione: il DOLORE
Il dolore assolutamente improvviso,
intenso e prolungato nel tempo
In base alla sede di partenza e di sviluppo
della dissezione il dolore pu essere
irradiato alla schiena e alladdome
 DISSEZIONE AORTICA
Presentazione: il DOLORE
Il dolore viene descritto come lacerante,
da strappo ed cos violento che spesso
i pazienti riferiscono di non aver mai
provato nulla di simile in tutta la vita
Non aggravato dagli atti del respiro o
dalla postura
DISSEZIONE AORTICA
Presentazione: il DOLORE
 DISSEZIONE AORTICA
Presentazione: altri sintomi
Sincope
Angina
Scompenso
Deficit dorgano
Anuria/oliguria
Deficit neurologici

 DISSEZIONE AORTICA
Diagnosi differenziale
Il dolore toracico uno dei sintomi pi
frequenti per il quale il paziente giunge al
DEA
Scarsa correlazione tra gravit della
patologia e entit del malessere toracico
I possibili benefici (o danni) conseguenti
a una corretta (o scorretta) valutazione
della sintomatologia sono enormi
 DISSEZIONE AORTICA
Diagnosi differenziale
Il dolore toracico deve essere
caratterizzato sulla base di:
Modalit di insorgenza
Sede del dolore
Fattori precipitanti
Carattere
Durata
Manovre o farmaci allevianti
 DISSEZIONE AORTICA
Diagnosi differenziale
Malattie cardiache:
Angina pectoris
Infarto miocardico
Pericardite
Prolasso mitralico
Ipertensione polmonare

 DISSEZIONE AORTICA
Diagnosi differenziale
Malattie polmonari:
Embolia polmonare
Pleurite
Pneumotorace
Mediastinite
Tumore
Tracheo-bronchite
polmonite
 DISSEZIONE AORTICA
Diagnosi differenziale
Malattie muscoloscheletriche:
Artrite della spalla
Costocondrite
Discopatia cervicale
Crampo muscolo intercostale
Sindrome dello scaleno medio
 DISSEZIONE AORTICA
Diagnosi differenziale
Malattie gastrointestinali:
Reflusso gastro-esofageo
Disordini motori esofagei
Colica biliare, colecistite acuta
Pancreatite
Sindrome di Mallory-Weiss
Ulcera peptica
 DISSEZIONE AORTICA
Diagnosi differenziale
Primo obiettivo:
Riconoscimento di un quadro clinico
minaccioso per la vita
Sindrome coronarica acuta
Tromboembolia polmonare
Dissezione aortica
Pneumotorace
Rottura dellesofago
DISSEZIONE AORTICA
Classificazione di Stanford
DISSEZIONE AORTICA
Classificazione di De Bakey
 TRANSTHORACIC ECHOCARDIOGRAPHY.

Transthoracic echocardiography has a sensitivity of 59 to 85

percent and a specificity of 63 to 96 percent for the diagnosis of
aortic dissection. Such poor sensitivity significantly limits the
general usefulness of this technique. Furthermore, image
quality is often adversely affected by obesity, emphysema,
mechanical ventilation, or small intercostal spaces.
For confirmation of the diagnosis patients often require more than one non-
invasive imaging study to characterise aortic dissection, with computed
tomography (CT) used in 61% of cases, echocardiography in 33%,
aortography in 4%, and magnetic resonance imaging (MRI) in only 2%.1

Upon admission in the emergent setting transthoracic echocardiography

(TTE) is useful inidentifying proximal aortic dissection and thus to diagnose
type A dissection in patients with shock. It is limited, however, in visualising
the distal ascending, transverse, and descending aortas in a substantial
number of patients.

Conversely, transoesophageal echocardiography (TOE) is highly

diagnostic in aortic dissection encompassing the entire thoracic aorta.
Although oesophageal intubation is required, TOE can be performed at the
bedside with immediate results. The diagnosis ofaortic dissection is
confirmed when two lumens are separated by an intimal flap
Artic linear artifact due to reverberations from calcific aortic wall
Right aortic leaflet prolapse in
aortic dissection
Repair of the
proximal aortic
stump in type A
dissection
 AORTIC ANEURYSMS

ANEURYSMS SECNDARY TO MEDIA

DEGENERATION
POST-TRAUMATIC ANEURYSMS
INFLAMMATORY ANEURYSMS
INFECTIVE ANEURYSMS
ANASTOMOTIC (POST-SURGICAL)
ANEURYSMS
Thoracic aortic aneurysms are much less common than aneurysms of the
abdominal aorta. Thoracic aneurysms are classified by the portion of aorta
involved (i.e., the ascending, arch, or descending thoracic aorta). This
anatomical distinction is important because the etiology, natural history, and
treatment of thoracic aneurysms differ for each of these segments. In
modern series, aneurysms of the ascending aorta occur most commonly (60
percent), followed by aneurysms of the descending aorta (40 percent),
whereas arch aneurysms (10 percent) and thoracoabdominal aneurysms
(10 percent) occur less often. Thoracoabdominal aortic aneurysm refers to
descending thoracic aneurysms that extend distally to involve the abdominal
aorta. Sometimes, the entire aorta may be ectatic, with localized aneurysms
seen at sites in both the thoracic and abdominal aorta.
At least one half of patients with thoracic aortic aneurysms are asymptomatic at
the time of diagnosis, with such aneurysms typically discovered as incidental
findings on a routine physical examination,TTE, chest radiograph, or CT scan.
When patients do experience symptoms, the symptoms tend to reflect either a
vascular consequence of the aneurysm or a local mass effect. Vascular
consequences include aortic regurgitation from dilation of the aortic root, often
associated with secondary congestive heart failure, or distal thromboembolism. A
local mass effect from an ascending or arch aneurysm may cause superior vena
cava syndrome as a result of obstruction of venous return via compression of the
superior vena cava or innominate vein.
Aneurysms of the arch or descending aorta may compress the
trachea or main stem bronchus and produce tracheal deviation,
wheezing, cough, dyspnea (with symptoms that may be
positional), hemoptysis, or recurrent pneumonitis. Compression of
the esophagus can produce dysphagia, and compression of the
recurrent laryngeal nerve can cause hoarseness. Chest pain or
back pain occurs in 25 percent of cases of nondissecting
aneurysms and result from direct compression of other
intrathoracic structures of the chest wall, or from erosion into
adjacent bone. Typically, such pain is steady, deep, boring, and at
times severe.
The morphology of an aortic aneurysm is typically either fusiform, which is
the more common shape, or saccular. A fusiform aneurysm has a fairly
uniform shape, with symmetrical dilatation that involves the full
circumference of the aortic wall. Saccular aneurysms, on the other hand,
have more localized dilatation that appears as an outpouching of only a
portion of the aortic wall. In addition, the aorta may have a
pseudoaneurysm or false aneurysm, which is not actually an aneurysm at
all, but rather a well-defined collection of blood and connective tissue
outside the vessel wall. This defect may result from a contained rupture of
the aortic wall.
Transthoracic echo is an excellent modality for imaging the aortic root,

which is important for patients with Marfan syndrome, but it does not

image the middle or distal ascending aorta well in many cases and is

particularly limited in its ability to image the descending thoracic aorta.

Look also descending aorta !
AORTIC DILATION IN AORTIC BICUSPID VALVE
Influence of aortic size on cumulative, lifetime incidence
of natural complications of aortic aneurysm. The
incidence of natural complications (rupture or dissection)
is plotted along the y axis, and the aortic size is plotted
along the x axis.