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
The Liver
• Lt & Rt Renal
Arteries
The Kidneys
• Mesenteric Arteries
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 repair
Extent 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 imaging
Less invasive femoral approach
For patients unfit for surgery
Thoracic + Vascular surgeons
Spinal drain required
Fabric 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 rehab
No pushing or heavy lifting
Procedure
Stage of Rehab
Thoraco-abdominal aortic
repair
Full rehab no special treatment
Type B Dissection
Awaiting 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 Roberts
Aortic Nurse Practitioner
Liverpool Heart & Chest Hospital
0151 600 1616 bleep: 2006
Office Tel No. 0151 600 1006
Email michael.roberts@lhch.nhs.uk