Everything you wanted to know about the aorta but were afraid to ask!

By Michael Roberts Aortic ANP

The Role of the Aortic Nurse Practitioner at the LHCH.

Commenced September 2011

Patient & relative clinical and follow-up support

Coordination of Aortic Patient Forum

Link for GP / dietician / physiotherapy / occupational therapy / cardiac rehab

Advanced practice

Msc and clinically trained

Aims :

• Anatomy & Physiology of the Thoracic Aorta

• Surgical Procedures

• Aortic Dissection

• Plans for the future?

Anatomy & Physiology of the Thoracic Aorta

Blood Flow

The Heart

The Aorta

The Abdomen

Limbs & Feet

The Heart & the Aortic Valve

Aortic Root, Ascending & Arch

The Descending

Aorta

The Coeliac Axis

Other useful arteries!!!

• The Hepatic Artery

• Lt & Rt Renal Arteries

• Mesenteric Arteries

The Liver

The Kidneys

The Gut

The Iliac Arteries… to the Iliac

arteries that divide downwards, carrying blood to the legs and feet.

Lets cut right through to the heart of the matter – the surgery

Thoracic Aortic Aneurysm

• Thinning and dilitation of the aortic wall

• Life threatening condition

• Atherosclerotic in origin

• Secondary to Marfan’s, aortitis, trauma, chronic

dissection or infection

• Categorized by position on the aorta

Shape & Location of the Aneurysm

A Fusiform Aneurysm A Saccular Aneurysm

Aortic Valve & Aortic Root & Ascending

Performed when patient is either symptomatic because of the aortic stenosis or if the aorta is 5.5cm or more. Median Sternotomy. Tissue or Mechanical Valve.

Thoraco-abdominal aneurysm repair

Thoraco-abdominal aneurysm repairExtent I – sub-clavian artery extending to level with the renal arteries

Extent II – sub-clavian artery extending to the bifurcation of the aorta in the pelvis

Extent III – from the middle of the descending aorta extending to the bifurcation of the aorta in the pelvis

Extent IV – upper abdominal aorta and extends to the bifurcation of the aorta in the pelvis

***Bifurcation – to divide into 2 parts****

Crawford Classification of Thoraco-abdominal aneurysms

TEVAR (Thoracic Endo-vascular Aortic Repair )

Pre / post op CT imagingLess invasive femoral approachFor patients unfit for surgeryThoracic + Vascular surgeonsSpinal drain requiredFabric tube + metal wire stents.

TAVI (Trans Aortic Valve Implant)

TAVI (Apical / Femoral)

Cardiology + Surgical Procedure

High co-morbidity / older patients

Less invasive than open heart

Aortic Dissection

Aortic Dissection (Acute / Chronic)

• Dissection Split in the medial layer of the aorta resulting in two lumen with active flow in both

• Dissecting aortic aneurysm Dissection in an aortic aneurysm Aortic dissection that has subsequently become aneurysmal

Classification (DeBakey and Stanford)

Stanford Type A Stanford Type B

Incidence • Stanford Type A 2 – 3 x commoner than a ruptured AAA • True incidence unknown

• Males >Females

• 80% Hypertensive

Natural History

• 50 % Untreated acute Proximal Aortic Dissections succumb within 48 HRS.

• 1% per/hour death risk

• 70% die within 2 months

• 90% die within 3 – 6 months

Aetiology

• Marfans or other heritable elastic tissue disorders: Turners, Noonan, Ehler-Danlos

• Unicuspid / Bicuspid Aortic Valves have 5 x more incidence of disseection

• In absence of elastic tissue disorders: Pregnancy and hypertension

• Iatrogenic

• Most believe that Atherosclerosis is coincidental rather than causative

Clinical Presentation

• Chest Pain: sudden, worst at onset but constant and may be migratory

• Marked anxiety

• Hypertension

• High incidence of suspicion essential for diagnosis

Patterns of Chest Pain in Dissection

Physical Signs

• New pulse deficit

• New murmur of aortic regurtiation

• Hypertension

• Hypotension: rupture, tamponade, obstruction of main coronary arteries

• Neurological deficits: paraplegia, ischaemic paralysis, Horner’s

• Signs of intrathoracic compression: SVC Syndrome, Vocal cord Paralysis

Radiology

Chest X-ray:

• bulging of the descending aortic

• deformity of the aorta knuckle

• displacement of the oesophagus

• mediastinal widening

• hazy aortic shadow

• tracheal or bronchial displacement

• pleural effusion

Further investigations: CT or MRI

Echo

Protocol from ward to rehab

Procedure Stage of Rehab

Aortic Root Replacement +/- AVR

Full Rehab no special treatment

Aortic Root Replacment + Hemiarch awaiting 2nd stage

Light active rehabNo pushing or heavy lifting

Procedure Stage of Rehab

Thoraco-abdominal aortic repair

Full rehab no special treatment

Type B DissectionAwaiting surgery

Very light rehab active rehab

Tevar / Evar(stent)

Light active rehab No pushing or heavy lifting

Procedure Stage of Rehab

Tavi (apical / femoral)

Full rehab no special treatment

Type A repair with residual dissection

Light active rehab No pushing or heavy lifting

Aortic ANP + Cardiac Rehab Team = Happy Patient

Contact Details:

Michael RobertsAortic Nurse PractitionerLiverpool Heart & Chest Hospital0151 600 1616 bleep: 2006

Office Tel No. 0151 600 1006Email michael.roberts@lhch.nhs.uk