79 years old female, DM,HTN,known IHD and had PCI 5 years back. Echo shows EF 45% with no significant wall motion abnormalities and moderate mitral regurgitation
Presented with sudden chest pain, haemoptysis and drop of Hb, BP 100/60mm Hg
CTA scan done by medical team included
What would be your assessment approach?
What would be your choice of modality for investigation?
What would be the plan of management?
What would be your follow up / surveillance plan?
Please support your answers with guidelines/evidence”
13 Comments
Ahmed Said
A1
Rupture aortic aneurysm dt PAU
Detailed history with analysis of pain and recent trauma
Complete by examination
…
A2
CTA
…..
A3
Resuscitation in Icu first of all
Than prepare for TEVAR
If there is no good landing area
Go with open
…..
A4
Regular imaging after intervention
Cta every 3 6 12 month
BP systolic 100 to 120
Pateint education
A1:
Most likely it is a case of AAS with ruptured PAU History taking and examination with detailed history of previous traumas
A2: CTA would be the best option
A3:
TEVAR would be the best choice
with ICU admission and stabilization with blood transfer control if needed.
A4:
MRA surveillance and follow up signs and symptoms to watch for marked improvement.
Sudden onset chest pain, associated with haemoptysis (coughing up blood), suggests a serious cardiovascular or pulmonary event. The drop in hemoglobin (Hb) could indicate active bleeding, possibly due to the ruptured penetrating aortic ulcer (PAU).
Risk Factors:
Diabetes Mellitus (DM), Hypertension (HTN), and a history of Ischemic Heart Disease (IHD).
Previous Percutaneous Coronary Intervention (PCI) 5 years ago suggests a history of coronary artery disease and possible ongoing vascular vulnerability.
Associated Symptoms:
Hemoptysis and chest pain are key symptoms; the drop in hemoglobin may indicate bleeding from the ulcer or a potential aortic rupture.
Blood pressure of 100/60 mmHg, indicating possible hypovolemic shock due to blood loss.
Assess for signs of organ perfusion, such as altered mental status, oliguria, or cool extremities.
Physical Examination:
Vital Signs:
Monitor BP, heart rate, respiratory rate, and oxygen saturation continuously.
Note the hypotension (BP 100/60 mmHg), suggesting potential hemorrhage or shock.
Cardiovascular Exam:
Check for any murmurs (for mitral regurgitation), tachycardia, or signs of heart failure.
Respiratory Exam:
Listen for any abnormal lung sounds (e.g., crackles, indicating possible lung involvement due to bleeding or fluid).
Neurological Status:
Assess for any neurological deficits that may suggest compromised cerebral perfusion due to bleeding or shock.
Choice of Modality for Investigation
Initial Imaging:
CTA (Computed Tomography Angiography):
Already done by the medical team, confirming the diagnosis of a ruptured penetrating aortic ulcer (PAU). This is the gold standard for diagnosing vascular pathologies, including aortic dissection or rupture.
CTA should provide detailed information on the extent of the PAU and any aortic involvement (e.g., dissection, aneurysms, etc.).
Additional Investigations:
Chest X-ray:
To evaluate for signs of hemothorax or other pulmonary pathology associated with the ruptured ulcer.
Coagulation Profile: PT, aPTT, INR, to assess for any coagulopathy, especially in the context of bleeding.
Renal Function: BUN, creatinine to check for any kidney compromise from shock or hypoperfusion.
Lactate Levels: To assess for tissue hypoxia, especially if there’s suspicion of shock.
Plan of Management
Acute Resuscitation:
Fluid Resuscitation:
Start with intravenous fluids (normal saline or Ringer’s lactate) to stabilize blood pressure and address hypovolemia due to hemorrhage. Use blood products if there’s significant blood loss (e.g., packed red blood cells, platelets).
Blood Pressure Control:
Target a systolic BP of around 100–120 mmHg to avoid excessive pressure on the aortic wall.
Use beta-blockers (e.g., IV labetalol or esmolol) to reduce aortic wall stress and prevent further rupture or dissection.
Pain Management:
IV opioids to control pain, which may help to reduce sympathetic stimulation and lower the risk of worsening hypertension.
Surgical or Endovascular Consultation:
Vascular Surgery or Cardiothoracic Surgery Consultation:
Given the diagnosis of a ruptured PAU, urgent consultation with a vascular or cardiothoracic surgeon is critical to evaluate for possible surgical repair (open or endovascular).
The decision to proceed with surgery depends on the size, location, and stability of the aortic ulcer.
Endovascular Repair: If the ulcer is in a favorable location, an endovascular approach such as stenting may be considered. This approach is less invasive and has a quicker recovery time.
Open Surgery: If the ulcer is large or involves multiple aortic branches, open surgery may be necessary to repair the rupture.
Frequent reassessment of blood loss and hemoglobin levels.
Close monitoring for signs of aortic rupture, shock, or any deterioration in clinical status.
Pain and sedation management to ensure comfort and reduce sympathetic stimulation.
Follow-up / Surveillance Plan
Post-acute Management:
Repeat Imaging:
After initial stabilization, repeat CTA (or MR angiography) should be done in 1–2 days to assess the resolution or progression of the PAU and any ongoing aortic complications.
Monitor Renal Function and Lactate Levels:
Ensure that renal function improves with adequate perfusion, especially if there has been significant blood loss or hypotension.
Long-term Follow-Up:
Regular Imaging:
Depending on the treatment (surgical or endovascular repair), repeat CTA or MRI should be performed at 3, 6, and 12 months to monitor for potential complications, including re-rupture or endoleak after repair.
Cardiology and Vascular Follow-up:
The patient’s diabetes, hypertension, and ischemic heart disease should be closely managed. Follow-up with cardiology and vascular surgery will be essential to monitor aortic health and manage comorbidities.
Medications:
Continue antihypertensive therapy (e.g., beta-blockers, ACE inhibitors, etc.) to reduce the strain on the aorta.
Consider antiplatelet or anticoagulation therapy depending on the specific management plan (surgical vs. endovascular).
Lifestyle Modification:
Address smoking cessation, weight management, and glycemic control to reduce cardiovascular risk.
Patient Education:
Explain the importance of monitoring for signs of complications (e.g., chest pain, new neurological deficits, leg swelling) and the need for regular follow-up imaging.
Advise on medication adherence, lifestyle changes (diet, exercise), and the importance of blood pressure control to prevent further aortic complications.
the diagnosis is Aortic Rupture secondary to a PAU (Penetrating Atherosclerotic Ulcer) with periaortic hematoma and hemothorax
⸻
A1 assessment Approach
history taking > analysis of the pain + history of recent trauma and previously diagnosed aneurysmal dilatation
full examination of pulsations
investigations
⸻
2. investigation of choice
• CTA is best according to ESVS guidelines level 2ac (already done) to Look for:
Extravasation of contrast
Periaortic hematoma
Pleural effusion (usually left-sided)
Signs of PAU with focal outpouching
⸻
A3 definitive Treatment > staged
1. Urgent Transfer to ICU
• Cardiac monitoring, invasive BP
• Oxygen, IV access, blood crossmatch
• Transfusion as needed
• Prepare for endovascular repair
2.TEVAR (Thoracic Endovascular Aortic Repair): First-line if anatomically feasible
• Lower perioperative risk than open surgery
• Recommended by ESVS guidelines for ruptured PAU
• Open surgery only if TEVAR not feasible (e.g., poor landing zones, anatomy)
Q1:
history taking and analysis of the pain and any history of recent trauma and history of previously diagnosed aneurysmal dilatation and full examination of pulsations and investigations
its a case of AAS mostly ruptured PAU
Q2:
multi-detector CTA is the modality of choice according to ESVS guidelines level 2ac
Q3:
blood cross matching and transfusion and permissive hypotension and urgent TEVAR
according to ESVS level 2A c
Q4:
follow up her signs and symptoms improvement and surveillance using MRA according to ESVS level 2 a c
A1:
A case of AAS with ruptured PAU
Assessment approach via history taking examination investigation management
A2:
CTA with axial cuts less than 1 mm with central line axis 3d reconstruction is of choice according to EVES guidelines
A3:
Prepare for TEVAR to treat the pathology
ICU admission stabilization of the ptn bl transfusion with bl pr control
Fitness for surgery cardiac pulm renal functions
A4:
Magnetic resonance imaging should be considered as an imaging modality to follow up patients with aortic endografts level IIa
For patients treated with endografts life-long imaging follow up with magnetic resonance angiography or computed tomographic aortography should be considered IIa
Computed Tomograpic Angiography Within 1 month and 12 months after
procedure
A1
Rupture aortic aneurysm dt PAU
Detailed history with analysis of pain and recent trauma
Complete by examination
…
A2
CTA
…..
A3
Resuscitation in Icu first of all
Than prepare for TEVAR
If there is no good landing area
Go with open
…..
A4
Regular imaging after intervention
Cta every 3 6 12 month
BP systolic 100 to 120
Pateint education
A1:
Most likely it is a case of AAS with ruptured PAU
History taking and examination with detailed history of previous traumas
A2: CTA would be the best option
A3:
TEVAR would be the best choice
with ICU admission and stabilization with blood transfer control if needed.
A4:
MRA surveillance and follow up signs and symptoms to watch for marked improvement.
I don’t think that would cover the DD in this case
Please go through history and CTA again
Would MRA surveillance be the best option by guidelines?
Choice of Modality for Investigation
Plan of Management
Follow-up / Surveillance Plan
Please avoid using AI for answers
the diagnosis is Aortic Rupture secondary to a PAU (Penetrating Atherosclerotic Ulcer) with periaortic hematoma and hemothorax
⸻
A1 assessment Approach
⸻
2. investigation of choice
• CTA is best according to ESVS guidelines level 2ac (already done) to Look for:
⸻
A3 definitive Treatment > staged
1. Urgent Transfer to ICU
• Cardiac monitoring, invasive BP
• Oxygen, IV access, blood crossmatch
• Transfusion as needed
• Prepare for endovascular repair
2.TEVAR (Thoracic Endovascular Aortic Repair): First-line if anatomically feasible
• Lower perioperative risk than open surgery
• Recommended by ESVS guidelines for ruptured PAU
• Open surgery only if TEVAR not feasible (e.g., poor landing zones, anatomy)
⸻
A4 Follow-up After TEVAR
• CTA at:1 month/6 months/12 months/Annually
• Strict BP control: SBP 100–120 mmHg
• Monitor graft integrity, endoleaks, aneurysm sac size
Good answer, do you think there is room for transfer to ICU or patient should be managed as emergency case directly to theatre for TEVAR ?
A1. My assessment approach would be focused on patient stabilization of vitals then proceed with investigation as CTA and CBC, cross matching
A2..
As long as patient blood pressure is stable CTA would be the best choice but the patient should be accompanied all the time
A3..
It is penetrating aortic ulcer with extravasation so emergent TEVAR WOULD BE THE BEST CHOICE
A4..
CTA or MRA according to ESVS guidelines
Would you please expand your answer more regarding ESVS guidelines of management
Q1:
history taking and analysis of the pain and any history of recent trauma and history of previously diagnosed aneurysmal dilatation and full examination of pulsations and investigations
its a case of AAS mostly ruptured PAU
Q2:
multi-detector CTA is the modality of choice according to ESVS guidelines level 2ac
Q3:
blood cross matching and transfusion and permissive hypotension and urgent TEVAR
according to ESVS level 2A c
Q4:
follow up her signs and symptoms improvement and surveillance using MRA according to ESVS level 2 a c
Well done, very methodical answer
A1:
A case of AAS with ruptured PAU
Assessment approach via history taking examination investigation management
A2:
CTA with axial cuts less than 1 mm with central line axis 3d reconstruction is of choice according to EVES guidelines
A3:
Prepare for TEVAR to treat the pathology
ICU admission stabilization of the ptn bl transfusion with bl pr control
Fitness for surgery cardiac pulm renal functions
A4:
Magnetic resonance imaging should be considered as an imaging modality to follow up patients with aortic endografts level IIa
For patients treated with endografts life-long imaging follow up with magnetic resonance angiography or computed tomographic aortography should be considered IIa
Computed Tomograpic Angiography Within 1 month and 12 months after
procedure
Very good, do you think the rule of ICU here comes before or after intervention after CTA obtained