Disorders of the Aorta

Chapter 37

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Aorta
 Largest artery
 Responsible for supplying
oxygenated blood to
essentially all vital organs

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Disorders of the Aorta
 Most common vascular
problems of aorta
 Aneurysms
 Aortoiliac occlusive disease
 Aortic dissection

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Aortic
Aneurysms

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Aortic Aneurysms
Definition
 Outpouching or dilation of
arterial wall
 Common problems
involving aorta
 Occur in men more often
than in women and in
whites more often than
African Americans
 Incidence ↑ with age
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Abdominal Aortic
Aneurysm

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Aortic Aneurysms
Definition
 Abdominal aortic
aneurysms (AAA)
 ¾ occur in abdominal aorta
 ¼ occur in thoracic aorta
 Most occur below renal
arteries
 The larger aneurysm, the
greater risk of rupture
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Aortic Aneurysms
Etiology and Pathophysiology
 Dilated aortic wall
becomes lined with
thrombi that can embolize
 Leads to acute ischemic
symptoms in distal branches

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Aortic Aneurysms
Etiology and Pathophysiology
 Causes
 Degenerative
 Congenital
 Mechanical
 Penetrating or blunt trauma
 Inflammatory
 Infectious

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Aortic Aneurysms
Risk Factors
 Age
 Male gender
 High BP
 Coronary artery disease
 Family history
 High cholesterol
 Lower extremity PAD
 Carotid artery disease
 Previous stroke
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Aortic Aneurysms
Genetic Link
 Bicuspid aortic valve
 Coarctation of aorta
 Autosomal dominant
polycystic kidney disease
 Ehlers-Danlos syndrome
 Obesity

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Aortic Aneurysm
Clinical Manifestations
 Ascending aorta/aortic arch
 Angina
 Transient ischemic attacks
 Coughing and shortness of
breath
 Hoarseness and/or dysphagia
 If presses on superior vena cava
 Decreased venous return
 Distended neck veins
 Edema of face and arms
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Aortic Aneurysm
Clinical Manifestations
 Abdominal aortic
aneurysms (AAA)
 Often asymptomatic
 Frequently detected
 On routine physical exam
 When patient examined for

unrelated problem (i.e., CT

scan, abdominal x-ray)

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Aortic Aneurysm
Clinical Manifestations
 AAA
 May mimic pain associated with
abdominal or back disorders
 May cause back pain,
epigastric discomfort, altered
bowel elimination, intermittent
claudication
 May spontaneously embolize
plaque
 Causing “blue toe syndrome”
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Aortic Aneurysm
Complications
 Rupture—serious
complication
 Rupture into retroperitoneal
space
 Bleeding may be tamponaded
by surrounding structures,
thus preventing
exsanguination and death.
 Severe back pain

 May/may not have back/flank

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Aortic Aneurysm
Complications
 Rupture—serious
complication related to
untreated aneurysm
 Rupture into thoracic or
abdominal cavity
 Massive hemorrhage
 Most do not survive long

enough to get to the hospital

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Aortic Aneurysm
Diagnostic Studies
 X-rays
 Chest – demonstrate
mediastinal silhouette and
any abnormal widening of
thoracic aorta
 Abdomen – may show
calcification within wall of
AAA
 ECG – to rule out MI
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Aortic Aneurysm
Diagnostic Studies
 Echocardiography
 Assists in diagnosis of aortic
valve insufficiency
 Ultrasonography
 Useful in screening for
aneurysms
 Monitors aneurysm size

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Aortic Aneurysm
Diagnostic Studies
 CT scan
 Most accurate test to
determine
 Anterior-to-posterior length
 Cross-sectional diameter

 Presence of thrombus

 Best type of surgical repair

 MRI
 Diagnose and assess location
and severity
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Aortic Aneurysm
Diagnostic Studies
 Angiography
 Anatomic mapping of aortic
system using contrast
 Not reliable method of
determining diameter or
length
 Can provide accurate
information about
involvement of intestinal,
renal, or distal vessels
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Aortic Aneurysm
Interprofessional Care
 Goal – prevent aneurysm
from rupturing
 Early detection/treatment
imperative
 Once detected
 Studies done to determine
size and location

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Aortic Aneurysm
Interprofessional Care
 Small aneurysm (4- 5.4
cm)
 Conservative therapy used
 Risk factor modification
 ↓ blood pressure

 Ultrasound, MRI, CT scan

monitoring every 6 to 12
months

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Aortic Aneurysm
Interprofessional Care
 5.5 cm is threshold for repair
 Intervention at >5 cm in women
with AAA
 Surgical intervention may
occur earlier in
 Patients with a genetic disorder
 Rapidly expanding aneurysm
 Symptomatic patients
 High rupture risk
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Aortic Aneurysm
Interprofessional Care
 Surgical therapy
 If ruptured, emergent
surgical intervention
required
 90% mortality with ruptured
AAAs
 Preop
 Hydration
 Stabilize electrolytes,

coagulation, and hematocrit

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Aortic Aneurysm
Interprofessional Care
 Surgical technique
 Open aneurysm repair (OAR)
 Incising diseased segment
of aorta
 Removing intraluminal
thrombus or plaque

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Surgical Repair of
Aneurysm

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Aortic Aneurysm
Interprofessional Care
 Autotransfusion reduces
need for blood transfusion
during surgery
 AAA resection
 Require cross-clamping of
aorta proximal and distal to
aneurysm
 Can be completed in 30 to
45 minutes
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Nursing Management
Assessment
 Thorough history and
physical exam
 Watch for signs of cardiac,
pulmonary, cerebral, and
lower extremity vascular
problems
 Establish baseline data to
compare postoperatively
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Nursing Management
Assessment
 Note quality and character
of peripheral pulses and
neurologic status
 Mark/document pedal
pulse sites and any skin
lesions on lower
extremities before surgery

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Nursing Management
Assessment
 Monitor for indications of
rupture
 Diaphoresis
 Pallor
 Weakness
 Tachycardia
 Hypotension

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Nursing Management
Assessment
 Monitor for indications of
rupture
 Abdominal, back, groin, or
periumbilical pain
 Changes in level of
consciousness
 Pulsating abdominal mass

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Nursing Management
Planning
 Overall Goals
 Normal tissue perfusion
 Intact motor and sensory
function
 No complications related to
surgical repair
 Thrombosis
 Infection

 Rupture

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Nursing Management
Nursing Implementation
 Health Promotion
 Alert for opportunities to
teach health promotion to
patients and their
caregivers
 Encourage patient to reduce
cardiovascular risk factors
 These measures help ensure
graft patency after surgery
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Nursing Management
Nursing Implementation
 Acute Care
 Patient/caregiver teaching
 Providing emotional support
for patient/caregiver
 Careful assessment of all
body systems

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Nursing Management
Nursing Implementation
 Acute Care
 Postop
 ICU monitoring
 Arterial line
 Central venous pressure (CVP) or
pulmonary artery (PA) catheter
 Mechanical ventilation
 Peripheral IV lines
 Urinary catheter

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Aortic
Dissection

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Aortic Dissection
 Often misnamed
“dissecting aneurysm”
 Not a type of aneurysm
 Result of a false lumen
through which blood flows

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Classification of Aortic
Dissection
• Aortic dissection is
classified based on
location of dissection and
duration of onset
• Type A dissection affects the
ascending aorta and arch
• Type B dissection begins in
the descending aorta

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Aortic Dissection

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Aortic Dissection

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Aortic Dissection
 Affects men more often
than women
 Occurs most frequently in
sixth and seventh decades
of life

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Aortic Dissection
Etiology and Pathophysiology
 Due to degeneration of the
elastic fibers in the
arterial wall
 Chronic hypertension
hastens the process
 Tear in inner layer allows
blood to “track” between
inner and middle layer
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Aortic Dissection
Etiology and Pathophysiology
 As heart contracts, each
systolic pulsation ↑
pressure on damaged area
 Further ↑ dissection
 May occlude major branches
of aorta
 Cutting off blood supply to
brain, abdominal organs,
kidneys, spinal cord, and
extremities
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Aortic Dissection
Clinical Manifestations
 Depend on location of intimal
tear and extent of dissection
 Acute Type A aortic dissection
 Abrupt onset of excruciating
anterior chest pain
 Acute Type B aortic dissection
 More likely to report pain located in
their back, abdomen, or legs

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Aortic Dissection
Clinical Manifestations
 Pain characterized as
 Sudden, severe pain in
anterior part of chest, or
intrascapular pain radiating
down spine to abdomen or
legs
 Described as “sharp” and
“worst ever”
 May mimic that of MI
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Aortic Dissection
Clinical Manifestations
 Cardiovascular, neurologic,
and respiratory signs may
be present
 If aortic arch involved
 Neurologic deficiencies may
be present
 Type A
 Disruption of blood flow in
coronary arteries and aortic
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Aortic Dissection
Complications
 Cardiac tamponade
 Severe, life-threatening
complication
 Occurs when blood escapes
from dissection into
pericardial sac

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Aortic Dissection
Complications
 Cardiac tamponade
 Clinical manifestations
include:
 Hypotension
 Narrowed pulse pressure

 Distended neck veins

 Muffled heart sounds

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Aortic Dissection
Complications
 Aorta may rupture
 Results in exsanguination
and death
 Hemorrhage may occur in
mediastinal, pleural, or
abdominal cavities
 Occlusion of arterial
supply to vital organs
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Aortic Dissection
Diagnostic Studies
 ECG to rule out MI
 Chest x-ray
 3-D CT scan
 MRI
 Transesophageal
echocardiography

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Aortic Dissection
Interprofessional Care
 Initial goal
 HR and BP control
 ↓ BP and myocardial
contractility to diminish
pulsatile forces within aorta
 Pain management

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Aortic Dissection
Interprofessional Care
 Drug therapy
 IV β-adrenergic blocker
 Esmolol (Brevibloc)
 Other antihypertensive
agents
 Calcium channel blockers
 Nitroprusside

 Angiotensin-converting enzyme

inhibitors
 Morphine Copyright © 2017, Elsevier Inc. All Rights Reserved.
Aortic Dissection
Interprofessional Care
 Conservative therapy
 If no symptoms
 Can be treated conservatively
for a period of time
 Pain relief, HR, and BP
control
 CVD risk factor modification
 Close surveillance with CT or
MRI
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Aortic Dissection
Interprofessional Care
 Surgical therapy
 Emergency surgery for
acute Type A aortic
dissection
 When drug therapy is
ineffective or when
complications of aortic
dissection are present
 Surgery is delayed to allow
edema to decrease and
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Aortic Dissection
Nursing Management
 Postoperative
 See aneurysm postop care
(discussed earlier)
 Discharge teaching
 Therapeutic regimen
 Antihypertensive drugs and side
effects
 If pain returns or symptoms
progress, instruct patient to
seek immediate help
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