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1、<p><p>&lt;p&gt;&amp;lt;p&amp;gt;&amp;amp;lt;p&amp;amp;gt;Diseases of the aorta Heart Disease Braunwald CV R4 李威廷醫師 Supervisor: 李貽恆醫師 Aorta ? Intima, media, adventitia ? ascending, arch, descending ? Aortic isthmus: arch-descending j
2、unction Aortic aneurysm ? Definition: pathological dilatation of the normal aortic lumen involving one or several segments ? Fusiform (common), saccular ? Pseudoaneurysm: well-defined collection of blood and connective tissue outside the vessel wall Abdominal aortic aneurysm ? Age (M55 y/o; F70 y/o)
3、 ? Atherosclerosis ? Infrarenal arota: no vasa vasorum at media ? Gene (Marfan, Ehlers-Danlos syndrome) ? Prevalence: 3% ? Aneurysm rupture: 80% into left retroperitonium cavity Abdominal aortic aneurysm ? Pain: most common, at hypogastrium or back, not affected by movement ? Asymptom ? Rupture tria
4、d: abdominal or back pain; palpable/ pulsatile abdominal mass; hypotension (45 cm; expanding rapidly (0.5 cm/year) ? Coronary angiography ? Medication control: Hyperlipidemia, hypertension, cigarette smoking ? CT follow up every 36 months Thoracic aortic aneurysm ? Descending aorta ascending aorta ?
5、 Cystic media degeneration: weakening aortic wall (elastic fiber degeneration) ? Marfan syndrome: autosomal dominant ? Ahterosclerosis ? Syphilis: ascending aorta ? Infectious aortitis / mycotic aneurysm Thoracic aortic aneurysm ? 40% asymptom, pain ? A-V shunt, superior vena cava syndrome (mass eff
6、ect), tracheal deviation, hematemesis ? CT, TEE TTE ? Surgery: 5cm (mean expansion rate= 0.43 cm/year) ? Op risk: 5% Thoracic aortic aneurysm ? Annuloaortic ectasia: elastic fiber degeneration + aortic regurgitation ? Aortic valve replacement Aortic dissection ? Tear in aortic intima ? Antegrade, re
7、trograde ? false lumen, intimal flap, true lumen ? Acute (2/3), chronic (1/3) ? Ascending (65%), arch (20%), descending thoracic (10%), abdominal (5%) ? Mortality: 1% per hour Aortic dissection ? Peak: 6070 y/o ? Hypertension, bicuspid aortic valve ? Marfan syndrome (cystic media degeneration) ? 3rd
8、 trimester pergnancy ? Blunt trauma ? IABP ? Prior cardiac surgery Aortic dissection ? Severe tearing pain (sudden onset), CHF, syncope, CVA, ischemic peripheral neuropathy, paraplegia, cardiac arrest, sudden death ? Anterior pain only: 90% ascending ? Interscapular pain only: 90% descending Aortic
9、dissection ? Hypertension (descending), hypotension (ascending) ? Pseudohypotension (involving brachiocephalic vessel) ? Pulse deficit (transient), AR, neurological finding (proximal, conscious level or spinal cord ischemia) ? AMI (RCA LCA) ? Pleural effusion (left side), cardiac tamponade ? Horner
10、syndrome Aortic dissection ? Calcium sign: 1.0cm (suggestive, not diagnostic) ? Normal CXR cannot exclude dissection ? EKG: LVH (1/3); absence of ST and T change; AMI (involving coronary a.) ? Initial diagnosis rate: 62% Aortic dissection ? Mortality: 25% (20% Peripheral artery diseasesrisk factors
11、Peripheral artery diseases Peripheral artery diseases Intermittent claudication: ? pain, ache, fatigue, or discomfort in the affected leg during exercise, particularly walking (oxygen demand) ? resolved with rest within few minutes ? Buttock, hip, thigh ? Gastrocnemius muscle is most common ? Walkin
12、g Impairment Questionnaire ? Arterial embolism, vasculitis / arteritis, secondary compression, lumbar sacroradiculopathy (neurogenic pseudoclaudication, standing) Peripheral artery diseases Rest pain ? Inadequate blood flow ? Skin fissure, ulceration, or necorsis ? DM neuropathy or ischemic neuropat
13、hy Peripheral artery diseases Physical examination: ? Absent pulse distal to the stenotic site ? Bruit of the stenotic site ? Muscle atrophy, hair loss, cool skin, poor healing, pressure sore, Peripheral artery diseases Peripheral artery diseases Ankle/brachial index (ABI): ? SBP ratio (normal: =1)
14、? ABI 0.9 : 95% sensitive for PAD ? ABI 050.8 with claudication: critical limb ischemia ? ABI 0.5 or ankle BP 55mmHG: poor ulcer healing MR angiography: 95% sensitivity and specificity Contrast angiography Peripheral artery diseasestreatment Risk factor modification Control DM, HTN, smoking cessatio
15、n Antiplatelet therapy: ticlopidine, plavix Exercise: improve maximal walking distance than PTA Angioplasty / stents and surgery ? Trental: RBC flexibility and anti-inflammatory ? Pletal: unknown ? Beta-blocker: controversial Thromboangitis obliterans ? Young smokers ? Medium and smalll vessels of t
16、he arms ? Cause unknown? Type I and III collagen ? Pain, digit ulceration, Raynaud phenomenon ? Abnormal allen test (2/3) ? Tx: Cessation smoking, prostacyclin analogue, Acute limb ischemia ? Arterial embolism (Af) ? thrombosis with plaque ruprure ? dissection, ? trauma &amp;amp;lt;/p&amp;amp;gt;&amp;lt;/p&amp;gt;&lt;/p&gt;</p></p>
