Acute Aortic Disease.. - Index of

196 Coady and Elefteriades
family members. We believe this represents the current standard of care. We image
parents, grandparents, siblings, children, and grandchildren. We image even more
widely if, as in so many families, there has been devastation by premature dissection
or death.
What size criteria should be applied for aneurysms of the aortic arch?
Arch aneurysms are far less common than ascending and descending aneurysms,
and, in fact, many arch aneurysms represent extensions from ascending or descending
aneurysms. We do not have criteria specific for the arch. We apply the ascending or
descending size criteria, depending on whether the arch aneurysm is most closely
related anatomically to the ascending or descending aorta in a particular patient.
What size criteria should be applied for saccular aneurysms?
We have not analyzed saccular aneurysms separately. However, we measure the
maximum diameter across both the saccular aneurysm and the adjacent aortic
lumen. If this dimension exceeds criteria, we operate. We also recommend surgery
for anatomically concerning saccular aneurysms—those with abrupt contours,
rapid growth, or thin walls.
What about intramural hematoma and penetrating aortic ulcers?
Intramural hematoma and penetrating ulcer of the aorta are variants on the aortic
dissection theme. These are what we call “no flap” acute aortic phenomena
(Fig. A). We use the dictum: “No flap, no dissection.” That is to say, an aortic
dissection is characterized by a flap running obliquely across the aortic lumen.
In intramural hematoma, there is no such oblique flap. In such cases, there
is often no intimal tear visible radiographically (by CT scan, MRI, or echocardiography).
Rather one sees only a crescentic rim of hemorrhage in the aortic wall.
The rim of hemorrhage is concentric with, not oblique to, the aortic circumference.
Some authorities feel these lesions are due to rupture of the vasa vasorum, leading
to bleeding within the aortic wall.
Penetrating aortic ulcers look like the name implies. In fact, if blinded as to
organ of origin, one would be hard-pressed to distinguish these from peptic ulcers
in the duodenum (Fig. B). It is thought that these ulcers represent leaking of
blood through an intimal defect deep into the layers of the aortic wall, creating
an ulcer crater.
Most authorities would agree that acutely symptomatic intramural hematomas
or penetrating ulcers of the ascending aorta should be treated by prompt,
if not immediate, surgical aortic resection—much like a typical ascending aortic
dissection. There is difference of opinion regarding intramural hematoma and
penetrating aortic ulcer in the descending aorta. Many authorities recommend
medical therapy with anti-impulse drugs. Especially in the Far East, where the
disease may be less virulent for some reason, conservative management is encouraged
(1). Indeed, it is clear that anti-impulse therapy will allow many of these
patients to be discharge alive from the hospital.