1. A 66 year old man has had for three
hours terrible “sharp-tearing”
intrascapular back pain. At the time of
onset, he was lifting a heavy box.
PMH; CAD,HTN
BP 210/134 HR 118 RR 28 T 98.6
He is in severe distress
2/6 diastolic murmur

2. A 72 year old female has over the
past 3 hours had severe aching left
arm pain.
Exam: 144/76, 68, 36.4, 22
Ashen left upper extremity with no
pulses
Remainder of exam is normal
A 62 year old male has the abrupt
onset of urinary incontinence and
weakness of both legs. He has had
three days of thoraco-lumbar back
pain.
Exam: 184/98, 68, 36.8, 18
Normal other than flaccid and
insensate lower extremities.

3. AORTIC
EMERGENCIES
Wayne Triner DO MPH FACEP
Wanganui District Health Board
State University of New York
Albany Medical College

4. The Normal Aorta
From Aortic Annulus to
Bifurcation
Ascending
Arch
Descending
Diameter 3cm to 2 cm.
Numerous Ostea
Intima, Media,
Adventitia, Pericardium

5. Thoracic Dissection
2.5 to 5 / 100,000
1/3 may go undiagnosed
Risk Factors
Hypertension
Age
Marfan’s
Crack

6. Pathogenesis of Dissection
Separation of layers within the media
Initiating Event
Intimal Tears
Progression of
Dissection
Sheer forces

7. Dissection Anatomy
Location of Tear
60% Convexity of
Sinus
10% Arch
30% descending
Aorta

8. Natural Course
Ascending Descending
(70% of all dissections)
70% chronicity
90% 72 hr mortality 10% operative
(1-2%/hour) mortality
50% Aortic Regurg 10% medical
15% operative mortality
mortality

9. Diagnosis
History
90% have pain
Physical Exam
Hypertension
Shock
Aortic Regurg
Branch Vessel
Occlusion
d-dimer

10. CXR Findings of Dissection
Wide Mediastinum
Increased Aortic Wall
Thickness
Left Pleural Effusion
Mass Effect
trachea
NG tube
left mainstem
bronchus
15% will have no
abnormality

11. Thoracic Aortic CT Angiogram

12. TEE
*

13. Medical Management
Sheer Forces dp/dt
dp dp
dt dt

14. Medical Management
Analgesia
Esmolol
Nitroprusside
Labatolol
Start in critical care setting (ED). If going to
maintain on medical therapy, transition to oral
within 24 hours of adequate control

15. Management
Decisions
Time to Diagnosis
Medical or Surgical
Based upon
classification
– A or B
Progression or
impending rupture
Branch vessel occlusion

16. TEVAR

17. A 63 year old male presents with sharp left flank
and testicular pain of progressing severity over
2 days. There has been no trauma, urethral
discharge, fever or scrotal swelling.
BP 186/102, HR 108, RR 20, T98.2
Abd: obese, mildly tender
GU: non-tender, non-enlarged testicles
normal scrotum, normal penis without
discharge
U/A: 1+ HEMATURIA

18. “Stone Protocol” CT

19. Who, When
Caucasian males Prevelance between 2%
> 60 yo and 8% of men > 60 yo
Family Hx More common in Maori
Smokers (8.9 vs 3.7 per 100,000)
~ 15,000 US deaths from
HTN
rupture
The Law of LaPlace
50% of ruptured AAAs
survive to hospital
50% mortality for those
reaching hospital

20. ED Bedside Ultrasound
Immediately available
In “definitive” exams*
Sens > 95%
Spec > 95%
Generally < 4 minutes

21. A 62 year old male presents with
severe sharp low back and flank pain
of two hours duration with associated
nausea and vomiting.
BP 90/P, HR 124, RR 32, T 96.6
pale, cool, diaphoretic, severe distress
Lungs CTA, HSRRR
ABD: pulsatile, tender large mass

23. Misdiagnosis
Most common misdiagnosis of AAA?
Terrible sharp back pain
Writhing on bed
60 year old male

24. AAA Repair

25. EndoVascular
Infra-renal
Aortic Repair
(EVAR)

27. Post Operative Complications of
AAA Repair
Early Late
Everything bad Open
Renal injury Aortoenteric
Cord injury Fistula
– Herald bleed
Peri-op MI
Distal emboli Graft Infection
EVAR
Endoleak
Migration
*

30. Endograft Complications

31. 85 yo female fell striking back.
X-ray obtained for lumbar tenderness. A) Notify the OR and
get a surgeon.
B) Obtain an
emergent
uncontrasted CT.
C) Have her seen in
vascular clinic the
next day.
D) Give her an enema.

32. At the End of the Day
Basic Awareness
Institutional Awareness
Supportive Strategies
Careful Planning