AKUT AORT SENDROMLARI

AkutAortSendromlariKapak

AKUT AORT SENDROMLARININ VARYANTLARI: İNTRAMURAL HEMATOM, PLAK RÜPTÜRÜ VE PENETRE ATEROSKLEROTIK ÜLSER

Yalçın Günerhan

Necmettin Erbakan Üniversitesi, Tıp Fakültesi, Kalp Damar Cerrahisi AD, Konya, Türkiye

Günerhan Y. Akut Aort Sendromlarının Varyantları: İntramural Hematom, Plak Rüptürü ve Penetre Aterosklerotik Ülser. Ünlü Y, editör. Akut Aort Sendromları. 1. Baskı. Ankara: Türkiye Klinikleri; 2025. p.121-129.

ÖZET

Akut aort sendromları (AAS); ani başlangıçlı, hayatı tehdit eden ve aort duvarında yapısal bozulmalara yol açan klinik durumlardır. Aort diseksiyonunun yanı sıra intramural hematom (İMH), penetre aterosklerotik ülser (PAÜ) ve plak rüptürü gibi varyant formlar AAS başlığı altında toplanır. Bu varyantlar farklı patofizyolojik mekanizmalarla oluşmalarına rağmen klinik semptomları büyük oranda benzerlik gösterir.

İMH, aort duvarında intimal yırtık olmadan vasa vasorum rüptürü sonrası media tabakasına kan sızmasıyla oluşur. PAÜ, aterosklerotik plağın intima ve internal elastik laminayı penetre ederek media tabakasına ilerlemesi sonucu gelişir. Plak rüptürü ise genellikle ileri aterosklerotik süreçlerin bir sonucu olarak endotel altındaki lipid çekirdeğin yırtılmasıyla meydana gelir.

Bu sendromların görülme sıklığı yaşla artmaktadır. Ayrıca hipertansiyon ve ateroskleroz gibi klasik kardiyovasküler risk faktörleri ile yakından ilişkilidir. AAS hastalarının büyük kısmında şiddetli, ani başlayan ve göğüsten sırta yayılan ağrı tipiktir. Bu hastalar sıklıkla miyokard enfarktüsü ile karıştırılabilir; dolayısıyla tanıda dikkatli olunmalı, BT anjiyografi, transözofageal ekokardiyografi (TEE) ve manyetik rezonans anjiyografi (MRA) gibi ileri görüntüleme yöntemlerinden yararlanılmalıdır.

İMH’un Tip A formları (asendan aortu tutan) yüksek komplikasyon riski taşıdığından cerrahi olarak yönetilmelidir. Tip B formları ise genellikle medikal olarak izlenir, ancak komplikasyon gelişmesi durumunda endovasküler tedavi (TEVAR) uygulanabilir. PAÜ ise özellikle komplikasyon gösteren, büyük veya semptomatik vakalarda TEVAR ile tedavi edilir. Plak rüptürü genellikle sessiz seyretmekle birlikte embolik olaylara neden olabilir; bu nedenle yakın izlem gerektirir.

AAS hastalarının takibinde klinik semptomlar, laboratuvar parametreleri (D-dimer, troponin, CRP vb.) ve görüntüleme bulguları rehberlik eder. Özellikle maksimum aort çapının >45 mm, hematom kalınlığının >10 mm olması gibi kriterler prognozu kötüleştiren önemli göstergelerdir. AAS, yüksek mortalite riski nedeniyle erken tanı, uygun tedavi stratejileri ve multidisipliner yaklaşım gerektiren bir klinik tablodur.

Anahtar Kelimeler: Intramural hematom; Penetre aterosklerotik ülser; Akut aort sendromu

Referanslar

  1. Evangelista A, Mukherjee D, Mehta RH, et al. Acute Intramural hematoma of the aorta: A mystery in evolution. Cir culation 2005;111:1063-70. [Crossref]
  2. Mody PS, Wang Y, Geirsson A, et al. Trends in aortic dissection hospitalizations, interventions, and outcomes among Medicare beneficiaries in the United States, 2000-2011. Circ Cardiovasc Qual Outcomes. 2014;7(6):920-928. [Crossref]  [PubMed]
  3. Mussa FF, Horton JD, Moridzadeh R, Nicholson J, Trimarchi S, Eagle KA. Acute Aortic Dissection and Intramural Hematoma: A Systematic Review. JAMA. 2016;316(7):754-63. [Crossref]  [PubMed]
  4. DeMartino RR, Sen I, Huang Y, Bower TC, Oderich GS, Pochettino A, et al. Population-Based Assessment of the Incidence of Aortic Dissection, Intramural Hematoma, and Penetrating Ulcer, and Its Associated Mortality From 1995 to 2015. Circ Cardiovasc Qual Outcomes. 2018;11(8):e004689. [Crossref]  [PubMed]
  5. Erbel R, Aboyans V, Boileau C, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 2014;35(41):2873-2926. [Crossref]  [PubMed]
  6. Mussa FF, Horton JD, Moridzadeh R, Nicholson J, Trimarchi S, Eagle KA. Acute Aortic Dissection and Intramural Hematoma: A Systematic Review. JAMA. 2016;316(7):754-63. [Crossref]  [PubMed]
  7. Bossone E, Eagle KA. Epidemiology and management of aortic disease: aortic aneurysms and acute aortic syndromes. Nat Rev Cardiol. 2021;18(5):331-348. [Crossref]  [PubMed]
  8. Sundt TM. Intramural hematoma and penetrating atherosclerotic ulcer of the aorta. Ann Thorac Surg. 2007;83(2):S835-S850. [Crossref]  [PubMed]
  9. Evangelista A, Maldonado G, Moral S, et al. Intramural hematoma and penetrating ulcer in the descending aorta: differences and similarities. Ann Cardiothorac Surg. 2019;8(4):456-470. [Crossref]  [PubMed]  [PMC]
  10. Murillo H, Molvin L, Chin AS, Fleischmann D. Aortic Dissection and Other Acute Aortic Syndromes: diagnostic Imaging Findings from Acute to Chronic Longitudinal Progression. Radiographics. 2021;41(2):425-446. [Crossref]  [PubMed]
  11. Vilacosta I, San Román JA, di Bartolomeo R, et al. Acute Aortic Syndrome Revisited: JACC State-of-theArt Review. J Am Coll Cardiol. 2021;78(21):2106-2125. [Crossref]  [PubMed]
  12. Banceu CM, Banceu DM, Kauvar DS, et al. Acute Aortic Syndromes from Diagnosis to Treatment-A comprehensive Review. J Clin Med. 2024;13(5):1231. Published 2024 Feb 21. [Crossref]  [PubMed]  [PMC]
  13. Vardhanabhuti V, Nicol E, Morgan-Hughes G, et al. Recommendations for accurate CT diagnosis of suspected acute aortic syndrome (AAS)--on behalf of the British Society of Cardiovascular Imaging (BSCI)/British Society of Cardiovascular CT (BSCCT). Br J Radiol. 2016;89(1061):20150705. [Crossref]  [PubMed]  [PMC]
  14. Moore AG, Eagle KA, Bruckman D, et al. Choice of computed tomography, transesophageal echocardiography, magnetic resonance imaging, and aortography in acute aortic dissection: International Registry of Acute Aortic Dissection (IRAD). Am J Cardiol. 2002;89(10):1235-1238. [Crossref]  [PubMed]
  15. Trimarchi S, Tolenaar JL, Tsai TT, et al. Influence of clinical presentation on the outcome of acute B aortic dissection: evidences from IRAD. J Cardiovasc Surg (Torino). 2012;53(2):161-168. [Crossref]  [PubMed]
  16. O’Gara PT, DeSanctis RW. Acute aortic dissection and its variants. Toward a common diagnostic and therapeutic approach. Circulation. 1995;92(6):1376-1378. [Crossref]  [PubMed]
  17. Stanson AW, Kazmier FJ, Hollier LH, et al. Penetrating atherosclerotic ulcers of the thoracic aorta: natural history and clinicopathologic correlations. Ann Vasc Surg. 1986;1(1):15-23. [Crossref]  [PubMed]
  18. Bossone E, Czerny M, Lerakis S, et al. Imaging and Biomarkers in Acute Aortic Syndromes: Diagnostic and Prognostic Implications. Curr Probl Cardiol. 2021;46(3):100654. [Crossref]  [PubMed]
  19. Filippone G, La Barbera G, Valentino F, et al. Conservative Management of Uncomplicated Acute Type B Intramural Hematoma of the Aorta Not Always Is the Right Solution. Ann Vasc Surg. 2019;61:469.e5-469.e11. [Crossref]  [PubMed]
  20. Morello F, Santoro M, Fargion AT, Grifoni S, Nazerian P. Diagnosis and management of acute aortic syndromes in the emergency department. Intern Emerg Med. 2021;16(1):171-181. [Crossref]  [PubMed]
  21. Riambau V, Böckler D, Brunkwall J, et al. Editor’s Choice Management of Descending Thoracic Aorta Diseases: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2017;53(1):4-52. [Crossref]  [PubMed]
  22. Ferrera C, Vilacosta I, Cabeza B, et al. Diagnosing Aortic Intramural Hematoma: Current Perspectives. Vasc Health Risk Manag. 2020;16:203-213. Published 2020 Jun 8. [Crossref]  [PubMed]
  23. Evangelista A, Czerny M, Nienaber C, et al. Interdisciplinary expert consensus on management of type B intramural haematoma and penetrating aortic ulcer. Eur J Cardiothorac Surg. 2015;47(2):209-217.
  24. Suzuki T, Bossone E, Sawaki D, et al. Biomarkers of aortic diseases. Am Heart J. 2013;165(1):15-25. [Crossref]  [PubMed]
  25. Suzuki T, Lyon A, Saggar R, et al. Editor’s Choice-Biomarkers of acute cardiovascular and pulmonary diseases. Eur Heart J Acute Cardiovasc Care. 2016;5(5):416-433. [Crossref]  [PubMed]
  26. Essat M, Goodacre S, Pandor A, Ren S, Ren S, Clowes M. Diagnostic Accuracy of D-Dimer for Acute Aortic Syndromes: Systematic Review and Meta-Analysis. Ann Emerg Med. 2024;84(4):409-421. [Crossref]  [PubMed]
  27. Vacirca A, Dias Neto M, Baghbani-Oskouei A, et al. Timing of Intervention for Aortic Intramural Hematoma. Ann Vasc Surg. 2023;94:14-21. [Crossref]  [PubMed]
  28. Ganaha F, Miller DC, Sugimoto K, et al. Prognosis of aortic intramural hematoma with and without penetrating atherosclerotic ulcer: a clinical and radiological analysis. Circulation. 2002;106(3):342-348. [Crossref]  [PubMed]
  29. Song JK, Kim HS, Song JM, et al. Outcomes of medically treated patients with aortic intramural hematoma. Am J Med. 2002;113(3):181-187. [Crossref]  [PubMed]
  30. Harris KM, Braverman AC, Eagle KA, et al. Acute aortic intramural hematoma: an analysis from the International Registry of Acute Aortic Dissection. Circulation. 2012;126(11 Suppl 1):S91-S96. [Crossref]  [PubMed]
  31. Li Q, Ma WG, Zheng J, et al. Distal Stent Graft-Induced New Entry After TEVAR of Type B Aortic Dissection: Experience in 15 Years. Ann Thorac Surg. 2019;107(3):718-724. [Crossref]  [PubMed]
  32. Herrán FL, Bang TJ, Restauri N, et al. CT imaging of complications of aortic intramural hematoma: a pictorial essay. Diagn Interv Radiol. 2018;24(6):342-347. [Crossref]  [PubMed]  [PMC]
  33. Evangelista A, Isselbacher EM, Bossone E, et al. Insights From the International Registry of Acute Aortic Dissection: A 20-Year Experience of Collaborative Clinical Research. Circulation. 2018;137(17):1846-1860. [Crossref]  [PubMed]
  34. Lovatt S, Wong CW, Schwarz K, et al. Misdiagnosis of aortic dissection: A systematic review of the literature. Am J Emerg Med. 2022;53:16-22. [Crossref]  [PubMed]
  35. Evangelista A, Dominguez R, Sebastia C, Salas A, Permanyer-Miralda G, Avegliano G et al. Long-term follow-up of aortic intramural hematoma: predictors of outcome. Circulation 2003;108:583-9. [Crossref]  [PubMed]
  36. Murray JG, Manisali M, Flamm SD, VanDyke CW, Lieber ML, Lytle BW et al. Intramural hematoma of the thoracic aorta: MR image findings and their prognostic implications. Radiology 1997;204:349-55. [Crossref]  [PubMed]
  37. Ganaha F, Miller DC, Sugimoto K, Do YS, Minamiguchi H, Saito H et al. Prognosis of aortic intramural hematoma with and without penetrating atherosclerotic ulcer: a clinical and radiological analysis. Circulation 2002;106:342-8. [Crossref]  [PubMed]
  38. Choi SH, Choi SJ, Kim JH, et al. Useful CT findings for predicting the progression of aortic intramural hematoma to overt aortic dissection. J Comput Assist Tomogr. 2001;25(2):295-299. [Crossref]  [PubMed]
  39. Lombardi JV, Hughes GC, Appoo JJ, et al. Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) reporting standards for type B aortic dissections. J Vasc Surg. 2020;71(3):723-747. [Crossref]  [PubMed]
  40. Goodacre S, Lechene V, Cooper G, Wilson S, Zhong J. Acute aortic syndrome. BMJ. 2024;386:e080870. Published 2024 Sep 17. [Crossref]  [PubMed]  [PMC]