DISEASES OF

THE AORTA
 ANATOMY
• Layers
1. Intima – thin
• Endothelium
• Subendothelial connective tissue
• Internal elastic lamina
2. Tunica media
• Smooth muscle cells
• Extracellular matrix
3. Adventitia (connective tissue)
 ANEURYSM

• Any pathologic dilatation of a segment of

blood vessel
• True aneurysms: all layers are involved
• Pseudoaneurysm: intima and media
• Fusiform: entire circumference is involved
(diffuse dilatation)
 Etiology and Associated Factors

• Aortic
– Atherosclerosis
– Cystic medial necrosis
– Chronic aortic dissection
– Infectious
– Trauma
Acute aortic syndrome
– Dissection, acute intramural hematoma,
penetrtating atherosclerotic ulcer
– Aortic occlusion: atherosclerosis
thromboembolism
Aortitis
– Vasculitis
– Rheumatic
– Idiopathic retroperitoneal fibrosis
– Infectious (SY, TB, mycotic)
 Thoracic Aneurysm

• Mostly asymptomatic
• Cystic medial necrosis-most common cause
of ascending aortic aneurysms
• Athrosclerosis: most common cause in
aneurysms of the aortic arch and
descending aorta
 Manifestations

• Ascending aneurysm
– CHF sec. to aortic regurgitation
– Marked compression of SVC
 Diagnosis

• Chest Xray
– mediastinal widening
– Displacement or compression of trachea or left
mainstem bronchus
• 2D echo
– Assess proximal ascending aorta
• CT with contrast/MRI
• Conventional aortography
 Treatment

• Beta blockers
• Surgery
– Placement of prosthetic graft
– Indications:
• Symptomatic
• >5.5-6 cm aortic diameter or
• >1 cm per year increase in aortic diameter
 Normal aorta

Aortic aneurysm
 Abdominal Aneursym

• Male>female
• Increases with age
• 90% of abdominal aneurysms with >4cm
are related to ATHEROSCLEROTIC
DISEASE
• Below the level of the renal arteries
 Physical Examination

ASYMPTOMATIC PATIENTS

• Palpable, pulsatile, expansile nontender

mass
• Incidental finding on ultrasound or
abdominal Xray
SYMPTOMATIC PATIENTS
• Emergency
• Strong abdominal pulsations
• Chest pain (lower back and scrotum)
 Diagnosis

• Abdominal Xray: calcified outline in 25%

• Abdominal ultrasound
– Mural thrombus
– For screening of relatives
– For serial documentation of aneurysm size
• CT/MRI with contrast
– Accurate
– Determine size and location
http://www.vasculardoc.net/content/aneurysms_aorta.html
 Normal aortogram

Aortic aneurysm
• Contrast aortography
– Risk: allergies
bleeding
atheroembolism
 Treatment

• Surgery and insertion of prosthetic device

• Mortality: 40-50% after acute rupture
 Acute Aortic Syndrome

1. aortic rupture (discussed)

2. Aortic dissection
3. Intramural hematoma with an intimal flap
4. Penetrating atherosclerotic ulcer
 Aortic Dissection

• Sec. to circumferential or transverse tear of

the intima
– Along the right lateral wall of the aorta
producing a false lumen
– Along the descending aorta below the
ligamentum arteriosum
• Initiating event
– Primary intimal tear with secondary dissection
into the media
– Medial hemorrhage that disrupts and dissects
into the intima

• Peak incidence: 6th and 7th decade of life

• Intramural hematoma: descending aorta
(trauma)
• Ulcer: erosion of plaque into the media
– Mid and distal portion of descending thoracic
aorta
– Sec. to ATHEROSCLEROSIS
 Acute valvular
insufficiency

dissection
 De Bakey Classification of Aortic
Dissection
Type I
– Intimal tears in the ascending and descending
aorta

• Type II
– Ascending aorta

• Type III
– Descending aorte with distal propagation
 Stanford Classification

Type A
– Ascending aorta (proximal)

Type B
– Descending aorta (distal)
 Predisposing Factors

1. Systemic hypertension
2. Coexisting conditions
– Marfan syndrome
– Pregnancy
– Trauma
3. Cystic medial necrosis
 Manifestations

• Sudden, tearing, • Loss of pulses

severe pain • Aortic regurgitation
(intrascapular, back) • Pulmonary edema
• Diaphoresis • Neurologic findings
• Syncope
• Dyspnea
• Weakness
• Hypertension
• hypotension
• Compression symptoms
– Acute aortic regurgitation
• >50% complication of proximal dissection
• Bounding pulse, wide pulse pressure, diastolic
murmur along the right sternum
• CHF
 Diagnosis

• Chest Xray
– Ascending: widened superior mediatinum. Left
sided effusion
– Descending: descending aorta appears to be
wider than the ascending aorta
• Transthoracic echo
– Proximal ascending aorta: >80% sensitivity
• CT/MRI
– intimal flap, extent, and involvement of major
arteries
– Sensitivity 90%
– Specificity 90%
– To differentiate intramural hemorrhage and
penetrating ulcer
– MRI: antegrade vs retrograde dissection
 Treatment

• Beta blockers
• Sodium nitroprusside
• May or may not use alpha/beta blockers
(labetalol)
• Alternative
– Calcium antagonist
– ACE inhibitors
• Surgery
– Excision of intimal flap
– Obliteration of false lumen
– Placement of interposition graft
• Major cause perioperative mortality
1. MI
2. Paraplegia
3. Renal failure
4. Tamponade
5. Hemorrhage
6. Sepsis
Type B: medical
10-20% mortality
 Aortic Occlusion

1. Chronic atherosclerotic occlusive disease

Distal abd. Aorta below the renal arteries
Claudication (buttocks, thighs,calves)
Dx: P.E.
leg pressure measurement
Duplex ultrasound
MRI/CT
Aortography
Tx:catheter-based endovascular procedure
1. Acute occlusion
– Distal aorta (abdominal)
– Enboli (from the heart)
– Ischemia of the lower extremities
– Absence of distal pulses bilaterally
Dx: CT/MRI, aortography
Tx: emergency thrombectomy or
revascularization
1. Aortitis
– Inflammation (Takayasu arteritis, giant cell
arteritis)
– Infections (TB, salmonella)
– Result in aneurysmal dilatation and aortic
regurgitation, occlusion of aorta
Takayasu
– Ascending aorta and aortic arc
– Young male Asians

Pathology
– panarteritis
– Mononuclear cells, giant cells, medial and
adventitial thickening, fibrotic occlusion
• Acute: fever, malaise, weight loss, Increased ESR
and CRP

• Chronic:
• upper extremity claudication
• Cerebral ischemia
• Syncope
POOR PROGNOSIS
Tx: steroids, surgical bypass
Giant cell arteritis
– Older patients
– Male>female
– Large,medium sized arteries

Pathology: focal granulomatous lesions (entire

abdominal wall)
• Complications
– Obstruction of mesium-sized arteries and major
branches of aorta
– Development of aortitis and aortic regurgitation
Rheumatic aortitis
– Ascending aorta
– Manifestation:
• Aneurysm
• Aortic regurgitation
• Involvement of cardiac conduction system
Syphilitic infective aortitis
– Staph, strep, salmonella, fungi
– Infects aorta at sites of atherosclerotic plaque
Mycotic
– Suprarenal
– Elderly
– Male>female
– Patholgy:
• Acute chronic inflammation
• Abscess
• Hemorrhage
• necrosis
Diagnosis
– CT/MRI
– Destruction of collagen and elastic tissues leads
to dilatation of aorta and scar formation
– Calcification
– Symptoms: sec. to AR, narrowing of coronary
ostia due to syphylitic aortitis, compression,
rupture
– Diagnosis: rapid plasmin reagin
fluorescent treponemal antibody
– Tx: surgical excision and repair, penicillin