00:01
Aortic Dissection.
00:02
So this is more
than just aneurysm.
00:05
This is in fact,
now we have had such dysfunction,
or abnormal matrix production,
that the media has become weakened and now
blood through a small tear in the intima
or by rupture of a
vessel vasa vasorum.
00:23
In the media, we get bleeding and
separation of the layers of the media.
00:29
Aortic dissection is in general
a surgical emergency,
particularly when it involves,
the proximal aorta, the ascending
aorta, and the aortic arch.
00:39
We'll talk about
that in a minute.
00:41
About 5-30 cases per
million people per year.
00:44
So it's not individually
a high incidence.
00:47
But overall for
350 million people,
there's significant numbers
of cases into the 1000s
that happen every year
in the United States.
00:57
It's more common in
men than in women.
00:59
And that's important
because the hypertension
that usually is the
underlying predisposition
is much more common
in men than in women.
01:06
It's more common in African
Americans than Caucasians,
although the numbers on
this are perhaps changing.
01:13
The peak incidence occurs
between ages 50 to 65.
01:17
So hypertension, is the number one
cause. 70% of dissection patients
where we've separated
the layers of the media
will be in patients who have
long-standing hypertension
as the major etiology
for the medial weakness.
01:32
Atherosclerosis can also be a cause
of disease and maybe 10-15% of cases.
01:38
And again, it's because we've increased
the diffusion distance from the lumen
into the inner
third of the media.
01:43
So we're going to get weakening
of the inner third of the media.
01:48
Obviously, connective tissue
disorders like Marfan Syndrome,
Loeys-Dietz syndrome,
Ehlers-Danlos Syndrome,
all of those are going to give rise to
an increased risk of aortic dissection.
01:59
The media is not a robust structural
entity in these various diseases.
02:05
And it takes very little
for blood under pressure
to kind of unzipper that media
and it can be catastrophic.
02:15
The histology in areas where
we're going to see dissection
shows basically cystic
medial degeneration,
that same accumulation of hyper
sulfated glycosaminoglycans
and diminished elastic tissue
and collagen synthesis.
02:30
That's what's indicated
with the arrow there.
02:33
Other causes for aortic
dissection can be inflammatory.
02:37
So certain forms of vasculitis
such as a giant cell arteritis,
or giant cell aortitis can give rise
to damage and destruction of the media,
which will give rise to weakening and
therefore potential for having a dissection
that separates the
planes of the media.
02:56
Takayasu Arteritis.
02:58
Typically involving the great vessels
that come off the arch
is just another form of
vasculitis that can do this.
03:06
And interestingly enough
anatomic abnormalities
bicuspid aortic valves
by whatever mechanism
that is driving the formation
of a bicuspid valve.
03:16
Shown there in the middle image.
03:19
The left hand side is a
tricuspid aortic valve.
03:22
The one second is a
bicuspid aortic valve,
and you can actually have
increased calcification,
which is what's shown
in the middle picture,
or you can have Myxomatous degeneration
and insufficiency of the valve.
03:34
Regardless of which
way the valve goes,
in patients with a
bicuspid aortic valve,
they also have a propensity
for abnormal aortic roots.
03:44
There is something about the genetics
driving the formation of the bicuspid valve
that also impacts the
smooth muscle cells
and their synthetic capacity
in that proximal aorta.
03:54
So they are prone to aortic
root dilation and dissection.
04:00
Coarctation of the aorta may also have
a cause by increasing local turbulence.
04:06
And by having abnormal
smooth muscle cell biology.
04:10
The arrow is pointing to
an area on this aortogram
after the great
vessels of the arch
are going up to
the head and neck
and you see the narrowing
of the aorta there.
04:23
Distal to that is where
you can have dissections
in the setting of
aortic coarctation.
04:30
Aortic dissections can also happen
following rapid deceleration.
04:34
Trauma, so we're looking here at
a horrific automobile accident.
04:38
The driver suddenly decelerated and the
heart internal organs pulled forward.
04:46
The heart is actually
tethered to the aorta
and the pulmonic architecture
via the ligamentum arteriosum.
04:54
And when you have a sudden deceleration
and pulling of the heart forward like that
that can rip the aorta
and cause a dissection.
05:02
So typical dissections involved with
motor vehicle accidents such as this
happen at the level of
the ligamentum arteriosum,
and not where most other
aortic dissections occurred.
05:14
Let's talk about
that in a minute.
05:18
Iatrogenic causes of aortic dissection
include prior cardiac surgery
or aortic surgery where you have
cut the vessels of the vasa vasorum,
again,
causing weakness of the wall
can occur with
cardiac catheterization.
05:30
You are shimmying
up a catheter from,
say a femoral artery up
into the arch of the vessels
and it's possible with some catheters
to actually undermine the intima
and get into the media and
cause a dissection plane.
05:46
So cardiac catheterization
can do this as well.
05:49
Certain drugs basically by causing
transient elevations in blood pressure,
such as amphetamines and cocaine
can also cause aortic dissections
in an otherwise weakened wall.
05:59
Most aortic dissections will occur within
the first 10 cm above the aortic valve.
06:06
So you can see the
myocardium at the bottom,
you can see the aortic valve,
and then you see a transverse tear
that's occurring in this case about
3 cm above the aortic annulus.
06:18
That's the classic location for the
vast majority of aortic dissections.
06:23
Trauma associated aortic dissections
occurred at the ligamentum arteriosum,
as I already said,
and that's what's being shown here.
06:30
In the circles we are seeing
where the tear occurred
in a patient who had a
sudden deceleration trauma,
where the heart got pulled
forward in that acute stop
and pulled and tugged on
the ligamentum arteriosum
and induced a tear
at that location.