Síndrome Aórtico Agudo

C. Benítez P CCVT HLV UG

Risk Conditions for Aortic Dissection

• Connective tissue disorders• Hereditary fibrillinopathies• Marfan’s syndrome• Ehlers-Danlos syndrome• Hereditary vascular diseases• Bicuspid aortic valve• Coarctation• Chronic hypertension and atherosclerosis• Smoking, dyslipidemia, cocaine/crack• Vascular inflammation• Giant cell arteritis• Takayasu arteritis• Behcet’s disease• Syphilis• Ormond’s disease• Deceleration trauma and iatrogenic origin• Deceleration trauma (car accident, fall from height)• Iatrogenic factors• Catheter/instrument intervention• Valvular/aortic surgery• Side or cross clamping/aortotomy• Graft anastomosis• Patch aortoplasty• Cannulation site

• El punto del desgarro intimal da la deficinicón del tipo .

…………………….………….. Y su pronóstico y

tratamiento

• Symptom Comment• Experience of pain Almost ubiquitous—96% of patients report pain• Location of pain Anterior characterizes ascending dissection;• posterior characterizes descending dissection• Severity of pain “10 out of 10”• Onset of pain Abrupt (distinguishes from MI)• Quality of pain “Tearing” quality• Variability of pain Classical patterns common, but not invariable;• 4% of patients experience no pain• Waxing and waning Variability in severity of pain reflects physiological• of pain (decrease in aortic wall tension with rx of BP) and• anatomic events (spontaneous re-entry).• Pleuritic component Reflects pericardial and pleural inflammation• Cardiac ischemia True anginal/infarction symptoms may occur from• involvement of RCA• Abdominal pain Vigilant search for intestinal ischemia essential• (lethal phenomenon)• Renal ischemia Usually asymptomatic, except in case of infarction• Leg pain From involvement of iliac artery by dissection• process• Paralysis of legs From spinal cord ischemia or peripheral nerve ischemia• (paraplegia)• Syncope From either:• Involvement of head vessels• Tamponade• Acute aortic insufficiency• Vaso-vagal response to pain• Dyspnea Acute aortic insufficiency poorly tolerated

Signs of Aortic Dissection

Sign Comment• Hypertension (or hypotension) Hypertension more common in descending dissection• Hypotension may signify tamponade• Aortic insufficiency AI murmur may hide• Pulse deficits Most common in an arm: “pseudo-

hypotension”• Fever Intense inflammatory response to dissection• Local signs in mediastinum Hoarseness (stretch of recurrent laryngeal nerve)• Tracheal obstruction (by aorta)• Hemoptysis (pulmonary rupture)• Hematemesis (esophageal rupture)• Continuous murmur (rupture into RA, RV, LA)

AngioTAC

AngioTAC 3d

MRI

MRI

• Desventajas :Mayor tiempo Metales Pcte inestable

Eco TE

Objetiva

• Flap de Disección

• Flujo o trombosis en falso lumen

Recordar

Todo es igual ????

Asociados a Válvula Bicúspide

• Recuerde

2% de la población Válvula bicúspide

• Recuerde :

• Gradiente medio > 30

= INTERVENCION

Que es mejor ???

Zonas de Landing

Clasificación de Crawford

Tipo I Desde el tercio superior de la aorta torácica hasta la parte superior de la abdominal. Incluye arterias viscerales.

Tipo II Desde el tercio proximal de la aorta descendente a la aorta infrarrenal.

Tipo III Empieza en los dos tercios distales de la aorta torácica y se extiende por gran parte de la aorta abdominal

Tipo IV Confinado a la aorta abdominal, incluyendo vasos viscerales

Identificação do real diametro do vaso

Lei de Laplace

Davies JE and Sundt TM (2007) Surgery Insight: the dilated ascending aorta—indicationsfor surgical

Crecimiento Aneurisma

Coady M. A. et al.; J Thorac Cardiovasc Surg 1997;113:476-491

Manejo en Urgencia

• Dx Diferencial:

TEP masivoSCANeumotórax a tensión

Manejo en Urgencia

• Analgesia• Stress de la Pared Vasodilatadores directos

Betabloqueo Descartar compromiso

visceral precoz.

No lo Olvide

• “There is no disease more conducive to clinical humility than aneurysms of the aorta”

Sir William Osler 1900