48 years old gentleman presented to emergency department with sudden chest and interscapular pain,
He has only history of DM,
No cardiac history
Hb 13 gm/dl
Emergency department called you and cardiology team to review the patient
CTA images included
What would your assessment approach (history taking , clinical examination, investigations and monitoring approach)
What should be the management plan and discussion with other teams
What would be your discussion with patient and family entitles
What is your inpatient stay goals and plan and discharge plan
3 days later during his admission on CCU under labetalol infusion, he developed right leg numbness and pain, and his kidney functions dropped by 20% and his lactate increased to 2.3
What would be the investigation of choice
What would be your management plan
What would be the discussion with the patient and family entitles
Please support your answers with guidelines/evidence
History of any connective tissue disease ?
examination involving b/p, bialteral upper and lower extremity pulsation assessment
investigation of choice is CTA
as seems to be uncomplicated type B dissection ,medical mgmt with bp control
as it progressed to malperfusionnof limbs, kidneys intervention is warranted, open or endogascular management, however endo is now less associated with morbidity 13% vs 30%
History of any connective tissue disease ?
examination involving b/p, bialteral upper and lower extremity pulsation assessment
investigation of choice is CTA
as seems to be uncomplicated type B dissection ,medical mgmt with bp control
as it progressed to malperfusionnof limbs, kidneys intervention is warranted, open or endogascular management, however endo is now less associated with morbidity 13% vs 30%
Q5: investigation of choice: CTA
Q6: management plan now is changed to intervention, as it’s now complicated dissection with TEVAR
I have to include these data in my plan;
1. The entry point
2. The secondary fenestrations
3. The distal extent of dissection
4. Proximal landing zone
5. The need for left subclavian artery bypass if I’m going to cover it
6. The need for further debranching procedure if more proximal arch branches will be covered
7. The need for spinal cord drainage
8. Reperfusion of renal and Mesentric vessels
9. Reperfusion of left leg by fem fem bypass
Very good
What would be the complications to be mentioned during discussion with patient and family and what would be your surveillance plan please
Q3: discussion with patient and family will include:
– potential complications of the condition
– possibility of intervention
– hazards of intervention like spinal cord ischemia, stroke
Q4: my stay goals
1. BP control: between 100 and 120
2. Pain control
Thanks
What would be parameters for monitoring and inpatient and discharge surveillance plan
Q1:
My assessment should include
1. Characterization of pain: onset, course, duration, location, radiation
2. Symptoms of organ malperfusion
3. Exam: vital signs, Bp equality
4. Full labs
Q2:
Management plan
First I have to confirm the dx (thoracic aortic dissection)
Second I have to know two things
1. Type of dissection (Stanford A or B)
2. Complicated or uncomplicated
In this case, it’s type B non-complicated, so first line of management is medical ttt.
1/
History:
personal history (smoking ,consumption of drugs-cocaine-,occupation ,activity)
family history ( similar conditions in family,Arterial disorders)
analysis of complaint (duration to determine class,description of pain)
Examination:
blood pressure and Heart Rate in both sides
periphral pulse to assess malperfusion
investigations:
ECHO
kidney function tests , CBC , Coagulation profile.
measurments of the false lumen/the anerysm.
monitoring:
should include Blood pressure and heart rate monitoring , pain and full labs.
2/
managment plan :
as the patient is acute uncomplicated my managment will be conservative on BMT and controle of BP & HR.
cardiopulmonary assessment.
3/
dicossion w family:
the managment plan ,the treatment options , the risk of intervention.
4/
Inpatient goals:
systolic BP between 100-120, HR below 90 .
close mointoring.
when Discharged : routine follow up
5/
Investigation of choice in such case: CTA
6/
managment : ergent TEVAR
7/
explain the chamge in events and risk for the patient and the need for ergent intervention now
Thanks for your answer
What should be target BP during ICU/CCU stay, what would be parameters of follow up during inpatient stay and on discharge and your surveillance plan please
During intervention , what would be the consideration to be taken into account please
1/Hx: onset course duration pain analysis family hx hx of previous episodes medications
Clinical: Abcd
Pulse prophecy discripancy hrt sounds abdominal examination
Investigation: full lab cardiac enz ecg cta
Monitoring vitals hr. bp icu
Good start short answer, I would like to have more input about what are parameters you are looking at you blood test and on CTA and what would be the management plan and inpatient and discharge orders please
What would be the investigation of choice?
I will repeat the CTA with bicarp solutions before contrast
Patients with acute type B aortic dissection who develop new or
recurrent abdominal pain and where there is any suspicion of
visceral, renal and/or limb malperfusion should undergo repeat
CT imaging. Level I C
For patients at increased risk of contrast induced nephropathy,
volume expansion with either isotonic sodium chloride or sodium
bicarbonate solutions should be considered before contrast
administration. Level IIa C
What would be your management plan
Now, it is considered failed medical control of the dissection, so i am going to think of TEVAR after proper planning to choose between fenestrated of not with or without fem fem cross over to reperfuse the right leg
In patients with complicated acute type B aortic dissection,
endovascular repair with thoracic endograting should be the first
line intervention. level I C
In complicated acute type B aortic dissection, endovascular
fenestration should be considered to treat malperfusion. Level IIa C
What would be the discussion with the patient and family entitles
why has the plan been changed
what is the complication of the intervention, and what would be the consequences if left untreated
Thanks a lot, very good answer
I will start with analysis of pain onset, course, duration, relieving and aggravating factors and recurrence. trying to figure out is it acute or chronic dissection
family history of the same condition, past medical history in details
then I will do complete vascular examination to exclude any diminished peripheral pulsations
regarding investigation, I will request full lab investigation including complete lipid profile and A1c. furthermore, I will also request ECG and Echocardiogram with consultation with the cardiology team to exclude Prescence of MI, aortic regurge, cardiac tamponade
CTA is recommended but itis already done
I will monitor Pain relief, Blood pressure, renal function
All patients with clinical suspicion of thoracic aortic disease and
abnormal chest radiograph should undergo computed tomographic
angiography for diagnosis confirmation. level I C
Multidetector computed tomographic angiography from thoracic
inlet to common femoral arteries should be considered as the first
line diagnostic modality for descending thoracic aortic pathology
level IIa C
For the diagnosis of descending thoracic aortic disease,
transoesophageal echocardiography should be considered as a
second line imaging modality when computed tomography is
unavailable, contraindicated, or inconclusive level IIa C
What should be the management plan and discussion with other teams
I will start with conservative measurement aiming to control blood pressure with B blocker as the first line, ensure vital organs perfusion, pain relief
I will discuss with cardiology team as mentioned above, also I may need renal team if renal function deteriorated, in addition to diabetic team to ensure glycemic control, finally anesthesia team incase of intervention needed
medical therapy should always be part of the treatment of patients
with acute type B dissection. level I C
In patients with acute type B aortic dissection, b-blockers should be
considered as the first line of medical therapy. level IIa C
In patients with acute type B aortic dissection who do not respond or
are intolerant of b-blockers, calcium channel antagonists and/or
renin-angiotensin inhibitors may be considered as alternatives or
complementaries. llevel IIa C
What would be your discussion with patient and family entitles
I will let the patient knows what is the disease, and its nature, possible complications, types of interventions( conservative, endo, open)
What is your inpatient stay goals and plan and discharge plan
I will start with medical conservative measure to control blood pressure with B blocker as the first line, ensure vital organs perfusion, pain relief. if controlled I will continue the management as a chronic dissection
discharge plan: blood pressure control, anti platelet and anti hyperlipidemia, with routine surveillance
In patients with chronic aortic dissection, effective antihypertensive
therapy should be given to reduce the risk of aortic related death. level I C
In patients with chronic dissection, measures to reduce cardiovascular
risk (such as treatment of hyperlipidaemia, anti-platelet therapy,
management of hypertension, and smoking cessa􀆟on) should be
implemented to reduce the incidence of late cardiovascular death. level I C
Long-term medical treatment with β-blockers should be given to
patients with chronic uncomplicated aortic dissection as they reduce
the progression of aortic dilatation, the incidence of subsequent
hospital admission, and the need for late dissection related aortic
procedures. level I C
In patients diagnosed with type B aortic dissection,
penetrating aortic ulcer, or intramural haematoma, routine
surveillance should be considered including physical
examination, echocardiography and imaging with magnetic
resonance angiography or computed tomographic
aortography. level IIa C
Very good , what would be the BP target when you discuss with ICU/CCU team please
systolic blood pressure between 100 and 120 mm Hg
ESVS 3.1.1.2 management of ATBAD
Good, thanks
Thanks for your case.
What would your assessment approach (history taking , clinical examination, investigations and monitoring approach)
I will start assessing this patient with complete history taking including any history of trauma in the past few days if he is smoker or not if there’s history of diabetes or HTN.
history of any similar conditions include another episode of chest pain with or without radiation is crucial.
I will take all vitals of the patient including HR,RR,Bl/p, O2 saturation.
I will examine his chest for pattern of breathing any bruises on the chest neck veins if congested or not, abdominal examination if there’s tender abdomen flank hematoma, examine both lower limbs and upper limbs for peripheral pulse, bilateral equality, motor power and sensation.
Investigation should include CTA to detect degree and type of dissection and any possiblle leakage and to plan for intervention.
Lab investigation include full lab investigation with special concern to any drop in Hb level and or elevation in serum Create level.
Monitoring inside CCU for Bl/P any increase in cardiac enzymes Hb level and any deterioration in the general condition.
What should be the management plan and discussion with other teams
Management with medical treatment with beta blockers to control blood pressure (systolic <130 with the possibility to add another vasodilator if not controlled by beta blockers alone.
also analgesics have a strong rule to treat severe agonizing pain
What would be your discussion with patient and family entitles
I will do my best to explain the patient condition with the family and the possible risk of rupture according to the aneurysm measures
What is your inpatient stay goals and plan and discharge plan
The goal is to control Bl/p control pain and continuous follow up if the aneurysm exceeded the threshold of 5.5 cm in diameter should be planned for intervention.
What would be the investigation of choice
Repeat the CTA to detect any leakage or further dissection and plan for intervention
What would be your management plan
TEVAR is the treatment of choice and is preferred over OSR in terms of mortality and morbidity
What would be the discussion with the patient and family entitles
The patient and family should be aware about the possible complications including aneurysm rupture,endoleak, stroke, paraplegia, and the need for continuous follow up with CTA.
Source
A systematic review of the recent evidence for the efficacy and safety relating to the use of endovascular stentgraft (ESG) placement in the treatment of thoracic aortic disease. Lisa Jones, Lynda Ayiku, Richard Wilson
Thanks a lot, very good input
Q1:fisrtly, I should revise hx of risk factors of AD as HTN, smoking, strenuous activities and positive family history.
Regarding to examination, I will search for manifestation of malperfusion like mesenteric ischemia, renal ischemia, lower extremities ischemia, pulse deficit and shock.
Investigation: Ist choice is CT angiography from ascending aorta down to arterial trees of both lower limbs with 1 mm slice.
Trans-esophageal echo is the second line when CTA is not available or contraindicated. (fig. 1)
Labs should include renal functions test, ABG and lactate level beside baseline tests.
Patient should be monitored in ICU for
a. Relieve or progression of pain
b. Vital signs stability
c. Appearance of new manifestation as peripheral or mesenteric ischemia.
Q2: Patient should be admitted in ICU to be stabilized by pain killer and antihypertensive agents, beta blocker is the first line.(fig.2)
I can involve cardiology and ICU for proper assessment and management.
Q3:Clear and frank discussion should be done with patient and his family about
a. Nature of the disease.
b. Goals of admission
c. Possible complication like extremities, mesenteric and renal ischemia
d. possibility of intervention in the future.
Q4:
Our goals are pain relieve , systolic BP below 130 mm hg and HR within 60-80 b/m.
During discharge, patient should be kept on antihypertensive drugs, strict control of risk factors, regular follow up and patient education of warning signs like refractory HTN, severe recurrent pain, severe abdominal pain and extremities paraesis or coldness.
Q5; New CT angiography (fig.3)
Q6: Now, patient can be classified as complicated ATBAD, where endovascular management is the 1st line, so proper assessment of CTA in coronal, sagittal and axial planes for accurate measurement is needed.( fig. 4)
Q7: Clear and frank discussion should be done with patient and his family about
a. Disease progression.
b. Benefit of intervention
c. Possible complications as stroke and SCI.
d. Risks of no intervention
Based on Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS) 2017
fig 1
fig 2
fig 3
fig 4
Thank you Ahmed for your answers, well done
Q1.
Detailed history regarding onset of the pain, site and character
Full complaint and if there are any co existing neurological or vascular complaints.
Co existing medical conditions . history of trauma . congenital diseases
Clinical examination includes Blood pressure measurement in both upper limbs, HR and vital signs recording, Neurological examination, peripheral vascular examination , and abdominal examination to exclude any visceral or ischemic complications due to aortic dissection
Investigation of choice is CT angiography of whole aorta ( esvs guidelines)
ECHO , full lab, ABG,
Monitoring of blood pressure and HR , urine output , kidney functions, ABG ( PH and serum lactate )
Q2. According to CT scan patient with Stanford type B aortic dissection ( Uncomplicated )
Further detailed assessment of the CT angiogram is mandatory for assessment of visceral arteries and level of affection of the dissection
Medical management is the choice in this acute non complicated phase ( esvs guidelines recommendation 13 class I)
IV Beta blockers should be considered as the first line of medical therapy ( esvs guidelines recommendation 14 class IIb )
Control of blood pressure between 100-120 mmhg and HR blow 60
Pain killers
Consultation and follow up by cardiology team is important.
Q3.i will clarify the recent conditions to the patient and his family with the management plan and discuss the risk of the condition and possible complications Despite the absence of complications at the time of presentation, these patients have an in hospital mortality of 3-10%.
possibility of intervention as in presence of complications intervention will be the first choice.
Q4. The main goals of treatment is to prevent further propagation of dissection
Monitoring of vital signs
Preserve and monitor visceral vascularity
Before discharge all iv agent should be turned to oral agents with strict plan to control blood pressure
Follow up with CT angiography after 6 months the once every 12-18 months
For follow up of level of dissection, visceral flow ,aortic diameter measurement and risk of aneurysm formation
Q5. Ct angiogram will still be first choice of investigation ESVS guidelines
Q6. TEVAR will be favorable treatment option ( ESVS recommendation 16 class I ,level of evidence C )
Q7. Again I will explain the recent condition and the progression of the case
I will explain the need for intervention and the risk of it
In the presence of complications (such as visceral, renal or limb ischemia, and/or aortic rupture), mortality rises to 20% by day 2 and 25% by day 30.
Like type A dissection, advanced age, rupture, shock, and malperfusion are important predictors of increased early mortality
Thanks a lot, very good answer
Do you think what happened to cause the transition from uncomplicated to complicated dissection
Just one thing to mention during discussion about intervention complications always mention stroke, cardiac risk, retrograde dissection and spinal cord ischemia/paraplegia
Regards
I think the cause of transition to this complicated scenario is due to impaired blood flow to renal or iliac artery as the dissection flap is reaching down to the level of iliac artey according to the attached CT
with increased pressure in the false lumen dissection flap may compress against true lumen leading to organ hypo perfusion or even acute ischemia
the clinical presentation change according to the type of this dissection flap ( static or dynamic ).
I will keep in mind those points about intervention complications
thanks a lot,
Very good , thank you
Q1 detailed hx is important site duration character radiation aggrevating and reliveing factors of pain associated symptoms of other systems GIT central and peripheral Nervous system compression symptoms lower limbs …etc
Medical hx HTN drug Hx familly hx hx of trauma
Clinical ex concious level vital signs BP HR RR peripherl vascular and neurological assessement abd ex cardiac assessment
Investigation cbc KFT ABG LFT Pt INR ESR CRP ECG ECHO
Monitoring of pain vital signs urine output cbc ABG KFT
Q2
C
Medical management( iv drugs ) include pain control and blood pressure reduction used beta blockers to limit aortic wall stress and to reduce the force of left ventricular ejection.
The goal is toreduce systolic blood pressure between 100 and 120 mmHg and, when attainable, the heart rate below 60 beats/min.
Class 1 recommendation
Q3
We should infome pt and family pt has ATBAD confirmed by CTA as pt is young we do workup to exclude some associated diseases at thus stage pt started medical ttt and be monitored to reduce risk of complication and may need to intervention if there is no response to medical therapy or complication occur.
these patients have an in hospital mortality of 3 – 10%.In the presence of complications
(such as visceral, renal or limb ischaemia, and/or aortic rupture), mortality rises to 20% by day 2 and 25% by day 30.
Q4.
The aims of treating ATBAD are to maintain or restore perfusion of the vital organs and to prevent both progression of the dissection and aortic rupture. Therefore, it is important to make a risk assessment at an early stage to determine the merits of medical, endovascular, or surgical intervention.
Discharge plan
The first follow up by CTA should be obtained prior to discharge from the initial hospitalization, and then at 6-month intervals. Once a dissection has been stable for two scans, follow-up imaging can be obtained on a yearly basis.
Q5
Paents with acute type B aorc dissection who develop new or recurrent abdominal pain and where there is any suspicion of visceral, renal and/or limb malperfusion should undergo repeat CT imaging
Claas 1 level C ESVS
Q6
TEVAR
In patients with complicated acute type B aortic dissection, endovascular repair with thoracic endogratiing should be the first line intervention
Cass 1 level C
In complicated acute type B aortic dissection, endovascular fenestration should be considered to treat malperfusion
Class lla level C
Q7
Pt developed COMPLICATED ATBAD in form of malperfusion kideny, LL and visera so he need urgent intervention Although TEVAR results in this setting are favourable, endovascular related complications can be devastating and may require revision with OR. Stroke is reported to occur in 3-10%.SCI 2%, LSA coverage lead to arm ischemia our complication related to device or procedure and in hospital mortality of 4%, and maybe we need to do CSF drainage to decrese risk of SCI.
Thanks for your answer, It is very good you mentioned CSF drainage consideration to reduce risk of SCI with intervention
Take history of the exact time of symptoms.
History of truma ,congenital heart disease (bicuspid or uni-commissural aortic valves),drug abuse, genetic disease (marfan syndrom ),strenuous activities, family history of AD and severe emotional stress.
If there abd pain , limb pain or paralysis
**Examination
Vital signs/ measure Bp on both upper limbs if there difference between both sides.
Neurologic examination exculde stroke or spinal cord ischemia
Full vascular examination exclude ischemia.
Abd examination exclude acute abd or mesentric ischemia .
**Full lab /kidney functions , lactate ,ABG.
ECG/ Echocardiogram to access cardiac function.exclude typeA aortic dissection.
**Control HR and BP is important target in this acute stage. Urine output.(jvascsurg)
Systolic BP 100-120 HR below 60
Pain killer is important.
**Mostly its non complicated aortic dissection type B axial cuts of CTA is also needed.
Medical treatment according to ESVS C1 with i.v beta-blocker.
Family should know about risk of complications malperfusion or rupture
And hospital mortality 3-10%.(ESVS)
60% will develop aneurysm during 5y (jvascsurg).
Follow up CTA after discharge 30d . Then intervals can reach upto 18-24maccording th follow up imaging .
follow-up for observations of
1-dissection extent
2-false lumen patency
3-presence aortic growth with diameter measurement. (JVASCSURG)
Good, waiting for your answers for the other half of the case
-After 3days patient become complicated ATBAD repeat CTA according to ESVS class I.
– thoracic endografting first choice for treatment class I
-according to CT and extension of the lesion my need carotid -carotid / subclavian bypass to achieve agood sealing zoon and avoid neurological complications (ESVS class IIa ).
– family should know whole plan of treatment. Mortality8% stroke8% SCI 2% Euro j vacs surg https://www.sciencedirect.com/science/article/pii/S1936879813009916
good input , thanks for your answer