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Preoperative evaluation for
aortic surgery
Inter-hospital Conference 2 (2/2554)
Aortic surgery:
Update & Decision making
วันเสาร์ ที่ 17 กันยายน 2554
ห้ องประชุ มสมาคมศิษย์ เก่าแพทย์ ศิริราช โรงพยาบาลศิริราช
นพ.วันชัย วงศ์ กรรัตน์
Acute aortic syndrome
1. Aortic dissection
2. Intramural Hematoma
3. Penetrating Atherosclerotic Ulcer
4. Pseudoaneurysms of the Thoracic Aorta
5. Traumatic Rupture of the Thoracic Aorta
Acute aortic syndrome
Acute surgical management pathway
Ascending Aortic dissection by imaging
Step 1
Determine no
suitable for Is pt a suitable candidate for Sx? Medical Tx
surgery
yes
Step 2
no
Determine
Is pt stable enough to allow pre-op testing?
stability for
preop testing yes
yes
no
Assess need Age > 40 yr
for preop CAG
no
Step 3 Known CAD?
Determine Significant risk factors for CAD?
likelihood of
coexistent CAD yes
no
Significant CAD by angiography?
yes
Plan for CABG if appropriate at time of AoD repair
Urgent operative management
Step 4
Intraoperative
evaluation of Intra operative assessment
aortic valve of aortic valve by TEE
Aortic regurgitation?
or
Dissection of aortic sinuses?
no
yes
Step 5
Surgical Graft replacement
intervention
of ascending aorta Graft replacement
+/- aortic arch of ascending aorta
and +/- aortic arch
repair/ replacement
of aortic valve or
aortic root
Acute aortic syndrome
Acute aortic syndrome
1. Perfusion Deficits and End-Organ Ischemia
2. Acute aortic regurgitation
3. Myocardial Ischemia or Infarction
4. Heart Failure and Shock
5. Pericardial Effusion and Tamponade
6. Syncope
7. Neurologic Complications
8. Pulmonary Complications
9. Gastrointestinal Complications
Acute aortic syndrome
• BP and HR
• 71% type B, 36% type A hypertension
• 20% hypotension ( cardiac tamponade, aortic
hemorrhage, severe AR, MI)
• Measure BP in both arms and legs
Evaluation and Management of Acute
Thoracic Aortic Disease
• Recommendations for Estimation of Pretest Risk
ofThoracic Aortic Dissection
Class I
1. specific questions about medical history, family history,
and pain features as well as a focused examination to
identify findings that are associated with aortic
dissection,
High risk conditions and historical features
• Marfan syndrome, Loeys-Dietz syndrome, vascular Ehlers-Danlos
syndrome, Turner syndrome, or other connective tissue disease.
• Patients with mutations in genes known to predispose to thoracic
aortic aneurysms and dissection, such as FBN1, TGFBR1, TGFBR2,
ACTA2, and MYH11.
• Family history of aortic dissection or thoracic aortic aneurysm.
• Known aortic valve disease.
• Recent aortic manipulation (surgical or catheter-based).
• Known thoracic aortic aneurysm.
High risk chest, back , abdomianl pain features
• Pain that is abrupt or instantaneous in onset.
• Pain that is severe in intensity.
• Pain that has a ripping, tearing, stabbing, or sharp quality.
High risk examination features
• Pulse deficit.
• SBP limb differential > 20 mm Hg.
• Focal neurologic deficit.
• Murmur of AR (new).
Evaluation and Management of Acute
Thoracic Aortic Disease
Laboratory testing
• D-dimer - venous thromboembolism,
sepsis, DIC, malignancies, recent trauma
or surgery, and acute MI
• Pre-surgical screening
• CBC, serum chemistry, coagulation
profiles, blood type and screen
Evaluation and Management of Acute
Thoracic Aortic Disease
Recommendations for Screening Tests
Class I
• ECG – all patients
• CXR( intermediate and low risk)
• Urgent and definitive imaging of the aorta using TEE,
CT, MRI is recommended to identify or exclude
thoracic aortic dissection in pts at high risk for the
disease by initial screening.
Class III
• A negative chest x-ray should not delay definitive
aortic imaging in patients determined to be high risk
for aortic dissection by initial screening.
Evaluation and Management of Acute
Thoracic Aortic Disease
Recommendations for Diagnostic Imaging study
Class I
1. Selection of a specific imaging modality to identify or
exclude aortic dissection should be based on patient
variables and institutional capabilities, including
immediate availability
2. If a high clinical suspicion exists for acute aortic
dissection but initial aortic imaging is negative, a
second imaging study should be obtained.
Evaluation and Management of Acute
Thoracic Aortic Disease
Recommendations for initial management
Class I
1. Control HR and BP
a. iv beta blockade titrated target HR of ≤ 60 bpm or less.
b. In pts with r contraindications to beta blockade,
nondihydropyridine calcium channel blocking agents should be
used as an alternative for
rate control.
c. If SBP ≥ 120 mm Hg after adequate HR control has been obtained,
then ACEI and/or other vasodilators should be administered
intravenously to further reduce BP that maintains adequate end-
organ perfusion.
d. Beta blockers should be used cautiously in the setting of acute AR
because they will block the compensatory tachycardia.
Class III
• Vasodilator therapy should not be initiated prior to rate control so as
to avoid associated reflex tachycardia that may increase aortic wall
stress, leading to propagation or expansion of a AoD
Evaluation and Management of Acute
Thoracic Aortic Disease
Recommendations for definite management
Class I
1. Urgent sx consultation should be obtained for all patients
diagnosed with thoracic AoD regardless of the anatomic
location (ascending versus descending) as soon as the
diagnosis is made or highly suspected.
2. Acute thoracic AoD the ascending aorta should be urgently
evaluated for emergent surgical repair because of the high
risk of associated life-threatening complications such as
rupture
3. Acute thoracic AoD involving the descending aorta should
be managed medically unless life-threatening complications
develop (eg, malperfusion syndrome, progression of
dissection, enlarging aneurysm, inability to control blood
pressure or symptoms)
AoD evaluation pathway
Step 1
Identify patient at Consider Acute AoD in all pt presenting with
Risk For •Chest, back, abdominal pain
acute AoD •Syncope
•Symptom consistent with perfusion deficit
High risk High risk pain
conditions High risk exam
features
•Marfan syndrome chest, back , abdomianl features
•CNT disease
+ •Pulse deficit.
Step 2 + •abrupt in onset.
Bedside risk •Fm hx of AoD. •severe in intensity •SBP limb
assessment •Known AV disease. •ripping, tearing diferential > 20 mm Hg.
•Recent aortic •stabbing
+ •Focal neurologic deficit.
manipulation •sharp quality •Murmur of AR (new)
•Known thoracic
aortic aneurysm
Determine pre-test risk by combination of risk condition, history, exam
Low risk intermediate risk High risk
Step 3
No high risk features Any single high ≥2 high risk features
Risk based risk features
diagnostic
evaluation Proceed with diagnostic
Immediate Sx consult
Evaluation as and imaging
clinically indicated
by presentation
yes
Primary ACS :
ECG: STEMI
reperfusion Tx
no yes yes
Alternative diagnosis
no
identified
yes Initiate appropriate tx
CXR : clear
alternate Dx
yes
no no yes
yes
Alternate Dx
Initiate Clinical suggest
appropiate Tx confirm
alternate Dx
by other
further testing
no no
Unexplained yes
hypotension or Expedited Ao imaging
widened mediastinum
no Expedited Ao imaging
Consider Ao TEE, MRI, CT
imaging
Step 4
Acute AoD
Identified of
excluded
If high clinical suspicious no Aortic dissection
AoD exists, present
consider secondary
imaging study
yes
Proceed to
treatment pathway
Initial management
• Once the diagnosis of AoD or one of its
anatomic variants (IMH or PAU) is
obtained, initial management is directed at
limiting propagation of the false lumen by
controlling aortic shear stress while
simultaneously determining which patients
will benefit from surgical or endovascular
repair
Initial management
• Blood Pressure and Rate Cont
targets HR <60 bpm
SBP 100-120 mmHg
• Pain control
• Hypotension : volume replacement, immediate operation
• For patients with hemopericardium and cardiac
tamponade who cannot survive until surgery,
pericardiocentesis can be performed by withdrawing just
enough fluid to restore perfusion
• Determine definite tx
Acute AoD management pathway.
Step 1
Immediate Arrange for definite Tx
post diagnosis
management
•Appropriate Sx consultation
Step 2
Innitial
management
aortic wall obtain accurate BP prior to beginning Tx
stress Measure in both arms
No hypotension/shock stage Yes
Intravenous rate
and pressure
control Anatomic based management
iv beta blocker /
calcium channel
blocker Type A dissection
Type B dissection
(HR < 60 bpm)
•Urgent Sx consult •Intravenous fluid
•Intravenous fluid bolus titrate to
Pain control
bolus titrate to MAP 70 mmHg
iv opiate
MAP 70 mmHg Or
Or Euvolemia
SBP > 120 mmHg Euvolemia •Evaluate etiology
•Review imaging Of hypotension
No tamponade contained rupture
Secondary pressure contained rupture cardiac function
Control severe AR •Urgent Sx consult
Intravenous vasodilator
(SBP < 120 mmHg) Etioligy of hypotension
Yes amenable to
operative management
No
Step 3
Definite
management
Yes
dissection involving No
the ascending aorta
ongoing medical Tx ongoing medical Tx
Operative or
Close hemodynamic
Intervational management Close hemodynamic
monitor
Maintain monitor
SBP < 120 mmHg Maintain
SBP < 120 mmHg
Complication requiring Complication requiring
Operative or Intervational Operative or Intervational
management management
Yes Yes
Malperfusion syndrome
Malperfusion syndrome Progression of dissection
Progression of dissection Aneurysm expansion
Aneurysm expansion Uncontrolled hypertension
Uncontrolled hypertension
Step 4 No
No
Transition to oral medicine out patient disease surveillance imagine
Recommendation for Medical Treatment of Patients
With Thoracic Aortic Diseases
Class I
• 1. Stringent control of hypertension, lipid
profile optimization,smoking cessation, and
other atherosclerosisrisk-reduction
measures should be instituted forpatients
with small aneurysms not requiring
surgery,as well as for patients who are not
onsideredto be surgical or stent graft
candidates.
Recommendation for Medical Treatment of Patients
With Thoracic Aortic Diseases
Recommendations for Blood Pressure Control
Class I
• 1. Antihypertensive therapy should be administered
tohypertensive patients with thoracic aortic diseases
toachieve a goal of less than 140/90 mm Hg
(patientswithout diabetes) or less than 130/80 mm Hg
(patientswith diabetes or chronic renal disease)
toreduce the risk of stroke, myocardial
infarction,heart failure, and cardiovascular death.
• 2. Beta adrenergic– blocking drugs should be
administeredto all patients with Marfan syndrome
andaortic aneurysm to reduce the rate of aortic
dilatationunless contraindicated.
Recommendation for Medical Treatment of Patients
With Thoracic Aortic Diseases
Recommendations for Blood Pressure Control
Class IIa
• 1. For patients with thoracic aortic aneurysm,
it isreasonable to reduce blood pressure with
beta blockers and angiotensin-converting
enzyme inhibitors or angiotensin receptor
blockers89,413 to the lowest point patients can
tolerate without adverse effects.
• 2. An angiotensin receptor blocker (losartan)
is reasonablefor patients with Marfan
syndrome, to reducethe rate of aortic
dilatation unless contraindicated
Recommendation for Medical Treatment of Patients
With Thoracic Aortic Diseases
• Recommendation for Dyslipidemia
Class IIa
• 1. Treatment with a statin to achieve a target LDL cholesterol of less
than 70 mg/dL is reasonable for patients with a coronary heart disease
risk equivalent such as noncoronary atherosclerotic disease,
atherosclerotic aortic aneurysm, and coexistent coronary heart
disease at high risk for coronary ischemic events
• Recommendation for Smoking Cessation
• Class I
• 1. Smoking cessation and avoidance of exposure toenvironmental
tobacco smoke at work and home are recommended. Follow-up,
referral to special programs, and/or pharmacotherapy (including
nicotine replacement, buproprion, or varenicline) is useful, as is
adopting a stepwise strategy imed at smoking cessation (the 5 A’s are
Ask, Advise, Assess, Assist, and Arrange
Recommendations for
Preoperative Evaluation
Class I
• 1. In preparation for sx, imaging studies extent of disease
and planned procedure. (Level of Evidence: C)
• 2. Pts with thoracic aortic dis. requiring a sx or catheter-based
intervention who have symptoms or other findings of
myocardial ischemia should Ix : significant CAD (Level of
Evidence: C)
• 3. Pts with unstable coronary syndromes and significant CAD
should undergo revascularization prior to or at the time of
thoracic aortic sx or endovascular intervention with
percutaneous coronary intervention or concomitant CABG .
(Level of Evidence: C)
Recommendations for
Preoperative Evaluation
Class 2 a
• 1. Additional testing is reasonable pulmonary
function tests, cardiac catheterization, aortography,
24-hour Holter monitoring, noninvasive carotid artery
screening, brain imaging, echocardiography, and
neurocognitive testing. (Level of Evidence: C)
• 2. For patients who are to undergo surgery for
ascending or arch aortic disease, and who have
clinically stable, but significant (flow limiting), CAD
it is reasonable to perform concomitant CABG (Level
of Evidence: C)
Recommendations for
Preoperative Evaluation
Class 2 b
• 1. For pts who are to undergo surgery
or endovascular intervention for
descending thoracic aortic disease,
and who have clinically stable, but
significant (flow limiting), CAD, the
benefits of coronary revascularization
are not well established. (Level of
Evidence: B)
