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Posts Tagged ‘false lumen’

Role of d dimer in acute aortic syndromes

D -Dimer is a marker of  intravascular fibrinolysis .It is a degradation product of fibrinogen. A level more than 500ng/ml is significant.In acute aortic dissection this level is reported to be more than 2000ng/ml.

The beauty of this molecule is it is elevated in three important chest pain emergencies.

  • Acute myocardial infarction
  • Pulmonary embolism
  • And now aortic dissection.

The issue is not simple , as we know any intravascular coagulation and lysis can elevate this molecule.In patients with chronic CAD as like a chronic thrombotic lesions within the coronary arteries can also elevate d dimer.

Similarly , in portal, cortical, deep venous thrombosis all result in elevated D dimer.

So , such a non specific test  , how can be  useful in the diagnosis of aortic dissection ?

Yes, you are right ,

D Dimer helps us  not in diagnosing aortic dissection but  helps us in ruling out a possible dissection

D-Dimer levels <500 has a negative predictive value of 98% .

What is the bio- chemical  dynamics of  D dimer in dissection ?

D dimer in aortic dissection is mainly secreted within the false lumen. For d dimer to secrete into  systemic circulation  the clotted area should be exposed to a adequately flushed systemic blood at a good perfusion pressure.The contact area between the clot and fresh blood  is of critical importance.

d dimer aortic dissection false lumen

So ,  even though it has been reported d dimer has near 100% negative predictive value . . . is there a chance a dissections might occur with normal  d dimer levels ?

Yes, very well possible with due credits to published data

  • A dissection without thrombus(Rare . . . but still possible !)
  • A clot confined to false lumen with entry or exit points sealed.
  • A dissection without a exit point.
  • Intramural hematoma with no communication with aorta

Infrequently asked questions

  1. Time window ? Dimers are mainly useful in  patients who report before 24h after the onset of chestpain.
  2. How long it takes for the dimers to  get excreted ?
  3. Can coronary dissections in STEMI elevate dimer ?

Final message

D dimer is  mainly useful in  “not making a diagnosing” aortic dissection.

If  dimer levels are strongly  positive and  clinically the patient  has  has no evidence for acute MI or acute pulmonary embolism  and continues to have chest/back/atypically located pain  suspect aortic dissection , and order for further imaging like TEE,MRI, MDCT etc.

* Do not forget the role of routine , simple bedside transthoracic and suprasternal echocardiogram.It can diagnose dissection correctly in good number of patients.

** Never oder for costly thoracic imaging whenever d dimer is elevated.

*** When you send the sample for dimer make sure to mention  the clinical likelyhood of dissection .If it is very high the lab has every reason to reject the sample and suggest you to go ahead with thoracic images.

This is because ,  it could be costly miss . . . if you depend on dimer to diagnose a dissection

Imagine this scenerio , while your patient has a absent left radial pulse due to dissection and you are waiting for the lab report to arrive !

Never use it for diagnosing aortic dissection.

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Coronary artery  perforation is a dreaded complication of PCI. Perforations are the Interventional cardiologists ultimate worry   as they need to  manipulate their  hardware for  long periods in many complex lesions.  Especially  it is a  real threat in chronic total occlusions.

Still , an important fact is ,  many of the coronary perforations are not life threatening ?

How is this possible ?

As the guide wire injures and perforates the cor0nary vessel,  it results in  small puffs of dye extravasating  into peri coronary space .

The coronary artery , which is located   within the  atrioventricular groove  (LAD), or AV groove (LCX, RCA) have  two distinct anatomical relationship with reference to epicardium and pericardial space.

50 % 0f circumference of the coronary artery is  hugged  by the myocardium  another 50% or so is related directly to the pericardial aspect.

Guide wires hitting on the myocardial aspects face a stiff resistance than the pericardial aspect. So , generally the risk of perforating pericardial aspect is more than myocardial aspect

Even if , the coronary artery is punctured on myocardial aspect , no great danger occur as there is no potential space for the blood to drain and further,  the  elastic nature of myocardial muscle plane effectively seals the leak. At the most , mild myocardial staining is noted .

coronary-perforation-2

While ,  perforations  into  the pericardial space  , often threaten with a tamponade. The fact that pericardial space has negative pressure and  the mean  coronary arterial pressure around 40mmhg ,  it is  , all the more likely blood is sucked into the pericardial  space. Of course , very minute  perforations  even into the pericardial space ,  could  be self limited and  benign.

coronary-perforation

What is unrecognised coronary perforation?

Many times , the guidewire goes in a false track in the tissue plane.This is  nothing,  but perforation without hemodynamic implication. Most often , these are the instances of guide wire entering the epicardium.They mimic , false lumen entry , dissections, etc. There are occasion , where false lumen of the  coronary artery were  stented.

What are the  factors which increase risk of perforation ?

perforation-6


How do you classify coronary perforations ?

perforation-3

How do you manage coronary perforation?

Anticipate the complication. Keep one cath lab  tamponade crash  bin  in ready mode before embarking upon a complex PCI

  • Self limited, none required  but requires close observaion for ext 24 hours.
  • Temporary balloon occlusion may be suffice in some cases
  • PTFE covered stents if prolonged leak.
  • Emergency surgery

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Why is identifying false and true lumen important ?

This helps the interventional cardiologist to plan the specific therapeutic procedure .

aortic-dissection-table

Is it really difficult to differentiate the two ?

One may wonder , why is that  difficult  to identify  the true aortic lumen by echo, after  all  , the LV empties the blood into true aortic lumen ! Yes  , in aortic root dissections  identifying the true from false lumen is rarely an issue.

aortic-dissection-4

The issue becomes  important and complicated as the propagation of dissection goes in a random and erratic way into the ascending aorta and arch and downwards.The situation could further get  complicated  by the fact there could  be multiple communication between the two lumens .Some of these communication are  hemodyanically patent others form  a simple anatomical continuity.The size and the configuration of true and false lumen are not uniform it is highly  variable.In the aortic root the size of the true lumen is usually  large and when it reach the descending aorta  as in type3 the whole thing could be reversed.

The enigma  of  these lumonomics , is that some of the native branches of aorta , would  either be, subtended by false or true lumen. This is a real tricky issue for the surgeons . If a aortic vessel branch (Say bronchial artery . . .) is perfused successfully by the  hemodynamically active false lumen should we meddle  that  at all ?


circumferential-dissection1 What are the types of false lumen ?

Usually single septae divide the aorta into two , one false lumen and true lumen.There can  be other types.

Triple lumen aorta :This is usually seen in the aortic root following dissection .Usually there is two false lumen and and one true lumen in the centre

Double barreled aorta: A circumferential   aortic dissection with a central true lumen surrounded by a  circumferential false lumen  mimicking a double barrel on within the other.

aortic-dissection

What determines blood flow within false lumen ?

  • Site of  intimal tear
  • Length of tear
  • Plane of cleavage  . Superficial  subinitmal tear with minimal  medial thickness is likey to give in easily  as the blood  dissects the plane  so it more often manifest as a flap  rather than sustained  dissection
  • Number  of exit points (It is often assumed  aortic dissection  there is typically one entrance and one exit point .

but  more  often  multiple exit points can occur. Some points can have both two and fro flow as it may act as both as entry or exit points

What  is the importance of identifying  point, exit point , true  lumen false lumen etc ?

  • This is vital for planning   repair  of  the segment
  • optimising side branch blood flow
  • some time one may require to create an exit point  for providing useful thermodynamics   of false lumen that could give branch to a vital area.

Why false lumen is  prone for thrombosis ?

  • Sluggish flow within false lumen
  • Plane of cleavage of intima  and media  create an  irregular surface that  trigger  tissue factor mediated thrombus.
  • Free floating cob webs   intimal  remnants may accelerate thrombus formation

What is the clinical significance of  finding  a thrombosed false lumen ?

Large thrombus can occur within false lumen.The presence of which , sometimes an advantage as

it limits further progression of false lumen (An organised thrombus is sort  of  natural  stent graft !)

many of these patients do well with medical management.

C J Sanderso Thorax 1981;36:194-199;

Can thrombus occur in true lumen also ? How common it is ? If so what is the mechanism ?

Yes , but it is rare  as the velocity  is  more .But it can occur in following situations.

  1. Preexisting atherosclerosis can be  a milieu for  insitu thrombus
  2. Thrombus in true lumen  can occur at the entry point where there is intimal tear ,  which  projects  into true lumen. that can  deccelerate the  flow(Rare)
  3. Thrombus in the false lumen may project into true  lumen  through another tear.
  4. Migration of false lumen thrombus may occur distally and reenter the  true lumen.

What is a cobweb ?

Cob web are the residual ribbons of dissected internal elastic lamina of aorta .
They are variably called as aortic bands, strands ,  septae, flaps etc.

What is the significance of the junction between false and rue lumen ?

The classic false lumen is crescent shaped. True lumen is either round or oval(Gibbous moon)
Tunction between false and true lumen has some characteristic feature.It mimics  the letter Y. The mainstem of Y correspond to main(  Normal full thickness)aortic  wall of the true lumen.The  oblique lines represent the outer wall of the false lumen and the septae dividing true (Fig 3)

dissection-41

What is the natural history of false lumen after surgical correction ?

Surgeons often leave the false lumen insitu , especially beyond the arch in type A dissection.

If false lumen is large  >70% of aorta , secondary dissections may occur in the long term.

Which is the best imaging modality  for  assessing dissection of aorta  ?

Even though MR angiogram and CT scans are shown to be good imaging tools in the evaluation of  dissection of aortamany practical issues creep in doing MR or CT angiogram.Many of these patients are too ill and will be on multiple arterial and venous lines Doing an MRI is  too dificult a task .Further these imaging modalities require a another arterial access .Requires contrast injection and  CT has in addition , radiation hazard.

TEE is a simple investigation can be done even in unstable patients in the bedside .Further also help us  us evaluate the aortic valve function and associated complications of dissection. TEE will be very useful peroperative also in assessing the repair.

*But MRI  and CT can give a long axis , saggital cuts of aortic dissection depicting the entry and exit points in a single image

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