1、急诊室经常遇到的急性主动脉疾病1 内容急性主动脉综合征主动脉夹层（AD）壁内血肿（IMH）穿透性溃疡（PAU）主动脉瘤 胸，腹破裂和即将破裂的迹象Acute Aortic Syndrome-Aortic Dissection(AD)-Intramural Hematoma(IMH)-Penetrating Atherosclerotic Ulcer(PAU)Aortic Aneurysm Thoracic,Abdominal-Rupture and Impending Rupture Signs2 Most common cause of acute aortic syndrome(70%)A
2、n intimal tear with separation of the aortic media into two layers 急性主动脉综合征最常见的原因（70%）主动脉壁内膜被分离成两层3 Classification 分类Type A DissectionType BDissection4 Type A:90%die within 3 months if not treated urgent operation Type B:medications or interventional treatmentA A型型：如不紧急手术治疗，三个月内死亡率大于90%；B B型型：药物或介入治
3、疗60%70%30%40%5 Chest Radiographic Findings胸片表现 normal in 10-40%widened mediastinum 61.1%displacement of aortic calcification 14.1%abnormal cardiac contour 25.8%正常10-40%纵隔增宽61.1%主动脉钙化14.1%心脏异常轮廓25.8%6 Role of MDCT angiography动脉动脉CTACTA作用作用(1)Sites of primary entry and re-entry;(2)Intimomedial flap,fa
4、lse and true lumen;(3)Extent of the dissection (4)Evidence of rupture;(5)Involvement of the aortic branches;(6)Abdominal aortic branch patency and evidence of end-organ malperfusion;(7)Morphology and diameter of the aorta along with the patency,size and tortuosity of the iliac and femoral arteries(u
5、seful for endovascular treatment planning)(1)(1)破裂入口和出口破裂入口和出口;(2)(2)内膜片，真假腔内膜片，真假腔(3)(3)夹层的程度夹层的程度(4)(4)破裂的证据；破裂的证据；(5)(5)主动脉分支受累；主动脉分支受累；(6)(6)腹主动脉分支通畅和终末器官灌注不良的证据；腹主动脉分支通畅和终末器官灌注不良的证据；(7)(7)沿着沿着通畅主动脉通畅主动脉的的形态和直径形态和直径，髂动脉和股动脉的大小和扭曲（髂动脉和股动脉的大小和扭曲（有助于有助于血管内治疗计划）血管内治疗计划）7 Unenhanced CT 平扫 Unenhanced
6、CT:-internal displacement of intimal calcifications Contrast-enhanced CT:-intimal flap that separates the true lumen from the false lumen CTCT平扫平扫钙化内膜内移增强增强CTCT内膜片分离出真假腔8 Classification：Stanford type A 9 Stanford type B10 False lumen-Larger cross sectional area(Pfalse Ptrue )-Delayed enhancement/thr
7、ombosis-Beak sign；Cobweb sign-True lumen:its continuity with an undissected portion of the aortaCobweb signBeak sign假腔假腔-截面积大(假腔 真腔 )-延迟强化/血栓形成-Beak sign；Cobweb sign-真腔:一直延续11 Complications of Thoracic AD并发症Acute aortic regurgitationMajor arch vessel obstruction,coronary artery involvementAortic rup
8、ture pericardium tamponade,left pleural cavity,mediastinum急性主动脉瓣关闭不全主动脉弓阻塞冠状动脉受累主动脉破裂心包填塞，左胸腔、纵隔12 Complications of Abdominal AD并发症 Main abdominal arterial branch involvement Aortic rupture:hemoperitoneum1主腹动脉分支受累主腹动脉分支受累2主动脉破裂腹腔积血主动脉破裂腹腔积血13 Malperfusion灌注不良Mortality 死亡率:3850%Incidence Main coronar
9、y artery 4.77%主冠状动脉 Carotid 6.628%颈动脉 Subclavian artery 5.617%锁骨下动脉 SMA2.311.9%肠系膜上动脉 Renal artery 3.212.4%肾动脉 Intercostal a.for spinal circulation 1.86.8%肋间动脉如脊髓循环 Iliofemoral artery 13.230%髂股动脉14 Branch Vessel Obstruction分支血管阻塞Static Occlusion:Intimal flap enters the branch vessel origin Thrombus
10、formationin the false lumenDynamic Occlusion:Intimal flap covers thevessel origin like a curtain Artery arising from the true lumen is compromised静态闭塞：内膜片进入分支血管的起始处，血栓形成在假腔动态闭塞：内膜片像窗帘覆盖血管起始处，起源真腔的动脉受到损害15 Dynamic occlusion:动态闭塞动态闭塞 -true lumen resembles a C-shaped envelope that is predominantly conc
11、ave toward the false lumen -treated with a fenestration procedure Types of branch-vessel occlusion分支血管闭塞的类型分支血管闭塞的类型16 Static occlusion:静态闭塞静态闭塞 -intimal flap intersects or enters the branch-vessel origin -treated locally with an intravascular stent Types of branch-vessel occlusion17 陷阱陷阱Pitfalls of
12、 MDCT Non ECG-gated CT:motion artifact pericardial recess mural thrombus in a fusiform aneurysm Periaortic fibrosis or mediastinal,pulmonary,or retroperitoneal tumorsPericardial Recess18 ECG-gated Vs.Non-ECG-gated 19 Management of acute aortic dissection20 How to write report Extent of dissection Lo
13、cation of intimal tear Identification of true/false lumen Malperfusion:side branch involvement Associated findings21 Spontaneous rupture of the vasa vasorum in the aortic wallA blood collection within the aortic wall with restricted flow/“dissection with restricted flow”22 Precontrast CT,narrow wind
14、ow“Hyperattenuating crescent”on precontrast CT No contrast enhancement,smooth margin 30%rate of progression to overt aortic dissectionAcute Intramural Hematoma急性壁间血肿急性壁间血肿 23 Subacute Intramural Hematoma亚急性亚急性壁间壁间血肿血肿 Subacute and chronic IMH(1 week after the onset of symptoms)Decreased attenuation(
15、identical to that in intraluminal blood)24 Differentiation of acute IMH from mural thrombus or thrombosed false lumen seen in AD Mural thrombus:more irregular lumen,non-displaced intimal calcification,more common in abdominal aorta,associated with aneurysm附壁血栓：更不规则腔，非移位性内膜钙化，更常见于腹主动脉，合并动脉瘤IMHAD w/th
16、rombosed false lumenMural thrombus25 AD false lumen thrombosis:multilayered pattern of increasing attenuationintimal flap(when you scroll up and down.)RadioGraphics 2009;29:791804AD26 Natural history of IMH10%16-47%20-45%27 Can resolve：followed 2 months.28 (a)Unenhanced axial CT image obtained at pr
17、esentation depicts a type B aortic intramural hematoma(arrow).(b)Contrastenhanced axial CT image obtained 1 month later shows an enhancing ulcerlike projection(arrow),a finding suggestive of a new intimal tear.(c)Contrastenhanced axial CT image obtained 2 months later shows overt dissection(arrow).C
18、an progress to dissection with ulcer like projection and dissection29 Can progress to fusiform aneurysm可进展为梭可进展为梭形动脉瘤形动脉瘤(a,b)Unenhanced axial CT images obtained at presentation depict a type B hematoma.(c)Contrast-enhanced axial CT image obtained 2 years later shows a fusiform aneurysm at the site
19、of the initial aortic intramural hematoma.30 F/70 acute chest and upper back pain2008-02-18 CT Angiography31 Observation acute chest pain2008-04-26 CT Angiography32 Differential Diagnosis鉴别诊断Pericaridal recessAortitis:diffuse,circumferential involvementRetroperitoneal fibrosis or periaortic lymphoma
20、 Thickened aortic wall enhances More commonly involve abdominal aorta CircumferentialRetroperitoneal fibrosisPericardial Recesspericaridal隐窝主动脉炎：弥漫，环周受累腹膜后纤维化或腹主动脉旁淋巴主动脉壁增厚更常见的涉及腹主动脉环33 F/23 palpitation,HA2010-07-07 CT Angiography40HU75HUTakayasus arteritis34 Type B IMH Primarily conservative Surger
21、y or stent-graft if recurring,refractory chest pain,evidence of increasing extent and diameter Type A IMH Emergency operation if there is cardiac tamponade,impending rupture,or rupture Conservative treatment35 How to write report Extent of IMH:type A or B Presence/absence of PAU or intimal tear If p
22、resent,location of PAU or intimal tear Signs of rupture/progression36 PENETRATING AORTIC ULCER穿透性溃疡Ulceration of atherosclerotic plaque-Disruption of the aortic media-Medial hematoma formation,localized-Potential for rupture-False aneurysm formationMid-thoracic or distal descending aortaDefinition:u
23、lceration of an aortic atherosclerotic plaque penetrating through the internal elastic lamina into the media。主动脉粥样斑块溃疡主动脉粥样斑块溃疡穿透内弹性膜进入管腔穿透内弹性膜进入管腔37 Plaque ulceration斑斑块溃疡块溃疡 Adventitial pseudoaneurysm血管外膜血管外膜假性假性动动脉瘤脉瘤Transmural rupture透壁破裂透壁破裂Intimal plaque ulceration内内膜斑膜斑块溃疡块溃疡Medial hematoma内内
24、侧侧血血肿肿Penetrating Atherosclerotic Ulcer穿透性溃疡 38 Natural history of PAUInitial diameter 20mm or depth 10mm 39 CT Findings Focal contrast-material-filled pouch communicating with the aortic lumen but extending outward beyond its expected aortic wall boundaries40 M/88 acute Lt.chest pain,underlying AGC
25、2005-05-06 Chest CT41 42/51DDx of Aortic Ulceration Atheromatous Ulcer No extension beyond expected margin of aortic wall No hematoma PAU Acute,life threatening Sometimes with IMH,hematoma or soft tissue infiltration Irregular margin IMH Concentrically located collection of blood within media smooth
26、ly AD Intimal flap extends across aorta Length more extensive43 44 Aortic Aneurysm Thoracic aortic aneurysmPermanent abnormal dilation of the aorta1.5 more than normal diameter 5cm in diameterNormal value:Asc TA 4cm/Desc TA 3cm in diameter45 46/65Aortic Aneurysm Causes Atherosclerosis Marfans Aortit
27、is Takayasus Behcets Giant cell Mycotic Syphylitic TraumaticTrue vs.pseudoFusiform vs.Saccular 47/51Abdominal Aortic Aneurysm Op indication Diameter over 5.5 cm Rapid size increase 7mm/6month 10mm/1 year Annual risk of rupture 8 cm 40-60%48/51Impending Rupture Pain Growing:1cm/6mo Perianeurysmal hem
28、orrhage Hyperdense cresent IMH or intrathrombic hemorrhage Density heterogeneity of intramural thrombi Eccentric lumen with thin wall Focal discontinuity of cal.Rim Recently abrupt breakFindings of Impending Rupture Increased aneurysm size ：diameter 7cm+acute symptoms（TAA 6 cm,AAA 7.2 cm）Thrombus an
29、d calcifications :thrombus to lumen ratio decreases as aneurysm increase；thick circumferential thrombus is protective against rupture Hyperattenuating crescent sign:acute or impending rupture(refer to PRECONTRAST CT!)Draped aorta sign:contained rupture49 Findings of Aneurysm Rupture动脉瘤破裂表现TAA:Hemope
30、ricardium,Hemomediastinum,Hemothorax(Lt)心包、纵膈、胸腔积血心包、纵膈、胸腔积血Aortobronchial,Aortoesophageal fistulaAAA:Retroperitoneal hematoma(Periaortic blood extending into the perirenal,pararenal space or psoas muscles)Aortoenteric fistulaExtravasation:immediate or delayed findingsFocal discontinuity in circumfe
31、rential calcifications unstable or ruptured aneurysm50 51/51Impending Rupture先兆破裂M/70Aneurysm rupture in a 65-year-old man.Nonenhanced CT scan shows a ruptured atherosclerotic aneurysm of the descending thoracic aorta.Note the high-attenuation fluid in the left pleural space,a finding that represent
32、s acute hemothorax.52 Aortobronchial fistula主动动脉支气气管瘘瘘Aortoesophageal fistula 食管主动动脉瘘瘘53 2011-11-07 outside CT M/73 Hemoptysis54 55 56 Aortoenteric fistula57 58 59/51Infrarenal AAAHyperdense crescent rim vs.Acute IMH高密度新月形边缘与急性IMH Histologically,hyperdense crescent rim seen at CT in large abdominal
33、aortic aneurysm is caused by fresh blood that first insinuates itself into the mural thrombus and later penetrates into the aortic wall IMH is caused by hemorrhage within the aortic wall AAA is more commonly associated with a chronic IMH than with an acute or subacute one Hyperattenuating crescent i
34、n association with fusiform aneurysm is discordant with subacute or acute IMH60 61 62 Impending rupture；Increased size of infrarenal AAA6.5cm-7.1cm.M/68 abdominal pain2008-11-27 CT AngiographyImpending rupture.Contained rupture casesIncreased size of infrarenal AAA 6.5cm-7.1cm.63 How to write report
35、 Extent of aneurysm Serial change of aneurysm size Proximal neck length(from left renal artery:AAA)Feature of impending rupture Associated findings64 Infected(Mycotic)Aneurysm感染（真菌）动脉瘤 most often pseudoaneurysm,prone to rupture(53-75%)endocarditis related septicemia/direct propagation from adjacent
36、vertebral OM,renal or psoas muscle abscess.Findings-saccular shape,lobular contours,eccentric thrombus-periaortic inflammation,abscess,and mass-periaortic gas and adjacent vertebral body abnormalities due to the spread of infection-fast expansion over time65 66 39067380 F/73 For fever focus w/u2010-
37、01-28 Abdomen CT67 SUV 3.82010-03-11 CT Angiography68 42231815 M/71 chest pain2011-09-12 outside Chest CT69 HU 202011-10-13 CT Angiography70 Traumatic Aortic Injury(TAI)外伤性主动脉损伤 Severe deceleration High speed motor vehicle accident Fall from a great height Immediate death in 80-90%Untreated:1%per ho
38、ur for 48 h71 Two TheoryShear btw fixed arch/mobile descending aortaOsseous pinch btw spine/anterior bony complexRadioGraphics 1997;2772 Traumatic Aortic Injury73 74 Traumatic Aortic Injury(TAI)外伤性主动脉损伤 Most common sites Aortic isthmus(90%)Ascending aorta(5-10%)Descending aorta near diaphragmatic ia
39、tus(1-3%)75 PDA remnant76 Direct sign直接征象 Pseudoaneurysm Abnormal aortic contour Abrupt change in aortic caliber Kinking of aorta(pseudocoarctation)Segmental occlusion of aorta Intimal flap Extravasation of contrast agent is rare 假性动脉瘤 主动脉轮廓异常 主动脉管径突变 主动脉迂曲（假性狭窄）主动脉段闭塞 内膜瓣 造影剂外渗是罕见的77 RadioGraphics
40、1997;2778F/71Motor vehicle accident(1MA)79 80 One week later81 82 RadioGraphics 2008;155583 Indirect sign-Less specific间接征象-缺乏特异性Mediastinal or retrocrural hematoma Not specific Can be from mediastinal venous bleeding Obscure fat plane surrounding aorta or arch vessels suspicious for occult acute TA
41、I further aortography84M/40Hoarseness(1MA)85 86 87/51Traumatic Aortic Injury 88/51ReferencesAnesthesia and Perioperative Care for Aortic Surgery,K.Subramaniam et al.(eds.),2011the Journal of Thoracic and Cardiovascular Surgery,2010,140,S92-97RadioGraphics 2010;30:445460 RadioGraphics 2009;29:537552R
42、adioGraphics 2007;27:497507RadioGraphics 2010;30:851867 RadioGraphics 2009;29:791804Asian Cardiovasc Thorac Ann 2010;18:456-463Heart 2001;85:365368 89 结束语当你尽了自己的最大努力时，失败也是伟大的，所以不要放弃，坚持就是正确的。When You Do Your Best,Failure Is Great,So DonT Give Up,Stick To The End谢谢大家荣幸这一路，与你同行ItS An Honor To Walk With You All The Way演讲人：XXXXXX 时 间：XX年XX月XX日
