Intervention case

Intervention case : 

Intervention case R1 Lee Hye Jin

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40/M 11723782 CC : abdominal pain onset :내원 직전

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33/F 11863988 CC : 내원 10분전 out car TA

Aortic dissection: 

Aortic dissection Cardiovascular emergency Prompt diagnosis and treatment Predisposing factor : hypertension (70~ 90%) - most important - common in distal than proximal dissection : congenital disorders of connective tissue - Marfan syndrome

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Categorized Acute : diagnosed within 2wks after 1st Sx Chronic : diagnosed after 2wks Mortality rate Immediate treatment : < 30% Untreated pts : high as 1~2% per hour during 1st 48 hrs after Sx : 36~ 72% of pts die within 48 hours of diagnosis 62~91% die within a week

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M/C complications : rupture of dissection into pericardium with progressive cardiac tamponade : occlusion of coronary or supraaortic vessels : severe aortic insufficiency with acute heart failure

Aortic dissection: 

Aortic dissection Mechanical forces contributing to AD : flexion forces of vessel at fixed sites radial impact of pressure pulse shear stress of the blood Begins with laceration of aortic intima and inner layer of aortic media -> forming entrance tear -> allows entering blood to split aortic media -> formation of double-channel aorta with aortic dissection flap dividing aortic lumen into true and false lumens

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Flap tissue : composed mainly of aortic media loss of elastic tissue reduce resistance of aortic wall → leading to subsequent dissection

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46/M

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★ Stanford classification Type A, B (whether or not ascending aorta is involved) Type A - dissections involve ascending aorta, regardless of site of intimal tear or distal extent - 60% of AD - risk of acute aortic insufficiency occlusion of coronary vessel rupture of dissection into pericardium → extremely high (~90%) - require immediate surgical intervention

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New treatment modality : surgical replacement of ascending aorta endoluminal stent-graft repair of descending aorta entry site Early intervention may limit extension of dissection ← SBP is no longer transmitted from aorta through large primary tear in intima

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Type B - distal to left subclavian artery - risk is lower in type B - 40% of AD - can be controlled medically # Complicated by progression of dissection, impending rupture, refractory HTN, localized false aneurysm, unremitting chest pain, end-organ ischemia → emergency surgery

Typical imaging features: 

Typical imaging features Classic feature of AD : partition formed by intimal flap between the true and false channels : found in 70% of cases Secondary findings : internal displacement of intimal calcifications or hyperattenuating intima : delayed enhancement of the false lumen : widening of aorta : mediastinal, pleural, or pericardial hematoma

Chest radiography: 

Chest radiography Progressive aortic enlargement on serial images Double contour of aortic arch Displacement of intimal calcification (> 6 mm) New pleural effusion and pericardial effusion Apparent displacement of intimal calcification may be projectional artifact Enlarged arch is not specific ← usually in hypertension or atherosclerosis Normal configuration of arch should not be interpreted as excluding AAD ← normal in 25% of AAD

78/M: 

78/M

CT: 

CT Rapid, relatively noninvasive, readily available method Sensitivity: 93.8% specificity :87.1% Intimat flap in 70% Increased attenuation of acutely thrombosed false lumen on NECT Internal displacement of intimal calcification

CT: 

Mediastinal or pericardial hematoma Delayed enh of false lumen Mural thickening with increased attenuation Irregular compression of true lumen by expanding intramural hematoma or thrombus Ischemia or infarction of organs supplied by vessels of false lumen CT

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43/M 78/M

MRI: 

MRI Sensitivity and specificity : 95~ 100% Intimal flap : intervening stripe of soft-tissue SI SI within false lumen :variable :depending on blood flow ( presence, age, composition of thrombus) Spin-echo MR : flow voids within both false lumen and true lumen Gradient-echo , phase-contrast MR : provide functional information

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23/M

MRI: 

MRI Pericardial or pleural effusion, mediastinal hemorrhage, aortic wall thickening : supporting diagnosis of AAD # Relatively long examination time Susceptibility to motion artifacts Need for regular cardiac rhythm Difficulties in patient monitoring ⇒ difficult to perform in acutely ill patient

Aortography: 

Aortography Standard diagnostic technique Sensitivity: 88%, specificity: 94% Intimal flap Supportive findings(wall thickening)may be absent if aorta lacks interface with lung Aortography is invasive and requires arterial puncture → not appropriate for acutely ill pts or low clinical suspicion

Stent graft indications: 

Stent graft indications Generally same as surgical treatment Poor medical condition ( CIx. for surgery ) ↔ anatomic problem (CIx. for endovascular Tx) ★ Stent-graft placement requires ▪ Adequate vascular access - sufficient diameter of iliac artery, abdominal aorta ▪ Without excessive tortuosity - neck extends > 15 mm above celiac artery

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In good surgical candidates : stent graft = surgery ?? In poor surgical candidates : stent-graft is usually indicated as elective or emergency procedure

Stent-Graft Placement: 

Stent-Graft Placement Usually under GA Stent-graft delivery system is inserted through surgical femoral cutdown Heparin (5,000 U) IV Iliac arteries are too tortuous or too small → through common iliac artery with use of temporary iliac artery conduit through infrarenal aorta SBP < 90 mm Hg :prevent stent graft migration during deployment Latex balloon is inflated within stent-graft → complete stent expansion

Follow-up: 

Follow-up Postimplantation syndrome :low-grade fever, back pain, mild leukocytosis, elevation of CRP :self-limiting resolves within 1 week without treatment Enh CT at time of discharge, 3, 6,12 mths after, annually thereafter Chest radiographs at same time

Technical pitfalls: 

Technical pitfalls After stent-graft insertion → closure of entry tear often spontaneously Excessive balloon dilation → expand aortic tear and weaken aortic wall → interfere close false lumen Dissections fail to close , result in aneurysms Retrograde extension of primary tear into ascending aorta after stent-graft of type B ⇒ Careful F/U

Adverse events: 

Adverse events In minority of cases Early adverse events : postimplantation syndrome : aortic or iliac artery trauma during procedure stent-graft misplacement renal failure, MI, pulmonary insufficiency, arterial embolism, paraplegia, stroke Late adverse events : endoleaks, stent-graft migration infection, fracture or erosion, aortic rupture

Endoleaks: 

Endoleaks Type 1 : incomplete sealing at attachment site : m/c endoleaks : high risk for aortic rupture Stent-graft landing zones are short, irregular, ulcerated Suboptimal stentgraft diameter Stentgraft is positioned in angulated neck in narrow aortic arch ⇒ more frequently

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2007-08-23 40/M 11723782

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2006-10-30 33/F 11863988

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Type 2 : persistent circulation in aneurysm from tributary to aortic lumen : unusual, less common Type 3 : defect of stent-graft membrane itself : separation of components in stent-grafts : stent-graft disconnection when multiple stent- grafts with short overlapping areas Type 1 and type 3 endoleaks : treated with longer stent-graft

Aortic perforation: 

Aortic perforation During stent-graft insertion After stent-graft insertion ← aortic wall erosion by stent-graft Rapidly enlarging hematoma or hemothorax Asymptomatic, aortic rupture, fistula formation Covering of perforation with stent-graft : TOC In curved landing zones, stent-grafts without proximal or distal uncovered stents : preventing aortic erosion

Iliac artery trauma: 

Iliac artery trauma Forced through small or tortuous iliac artery Premature interruption of stent-graft procedure Small, heavily or circumferentially calcified iliac arteries → iliac artery dissection or rupture ↑ Treated with stents or stent-grafts, surgical endarterectomy or bypass

Stent-Graft misplacement: 

Stent-Graft misplacement BP is too high during deployment or balloon dilation of the stent-graft Positioned across angulated arterial segment More flexible stent-graft Covering longer segment in angulated structure → prevent