0071643192.pdf

CARDIOVASCULAR EMERGENCIES

Endoleak=leak outside of

graft lumen, but within

existing aneurysm sac.

Proximal aortic dissections =

surgical management.

Distal aortic dissection =

medical management.

■ Graft complications

■ Graft infection

■ Secondary aortoenteric fistula

■ Endoleak:Leak outside of graft lumen, but within existing aneurysm

sac (continued risk for AAA rupture!)

THORACICAORTICANEURYSM

Often an incidental finding on chest radiography. A thoracic aorta diameter

of>4.5 cmis considered aneurysmal. Risk factors are similar to those for AAA.

Risk of rupture is high when diameter ≥6 cm.

SYMPTOMS/EXAM

■ Typically asymptomatic unless expanding, ruptured, or compressing adjacent

structure

■ Chest or back pain

■ Congestive heart failure if associated aortic insufficiency

■ Pericardial effusion if aortic valve involvement

■ Hoarseness: Compression of recurrent laryngeal nerve

■ Cough, wheezing with compression of trachea

■ If ruptured: Hypotension and shock

DIFFERENTIAL

■ Includes ACS, PE, aortic dissection, pneumothorax, esophageal rupture

DIAGNOSIS

■ CXR: May appear normal, but often shows wide mediastinum, enlarged

aortic knob

■ CT is confirmative.

■ Use TEE in the unstable patient.

TREATMENT

■ Resuscitation and immediatesurgical consult for repair if unstable patient

■ Aggressive BP control as with aortic dissection

■ Asymptomatic aneurysms can be scheduled for repair based on aneurysm

size and patient comorbidities.

A 55-year-old male with a history of poorly controlled HTN presents after

a syncopal event while lifting weights at the gym. He complains of severe,

sharp, left-chest pain and is diaphoretic and apprehensive. His initial BP is

88/55 and HR is 122. Exam reveals equal breath sounds, prominent JVD, distant

heart tones, and weak radial pulses. What is the best initial imaging study?

Bedside cardiac ultrasound. This patient is too unstable for CT. Ultrasound

will demonstrate pericardial effusion and tamponade from proximal aortic dis-

section, indicating the need for emergent surgery.

Aortic Dissection

Aortic dissections are classified by their location (see Figure 2.17). Location has

important implications for management as proximal (ascending) dissections are

managed surgically and distal dissections are typically managed medically.