Vasküler Nedenli Karın Ağrıları (2): Aort Disseksiyon ve Anevrizması
Özet
Bu bölümde aort diseksiyonu ve aort anevrizmaları, akut aortik sendrom spektrumu kapsamında ele alınmıştır. Aort duvarının anatomik ve histopatolojik özellikleri ayrıntılı olarak açıklanmış; diseksiyon ve anevrizma gelişiminde rol oynayan mekanik, moleküler ve hücresel patofizyolojik süreçler güncel literatür ışığında tartışılmıştır. Aort diseksiyonunun Stanford ve DeBakey sınıflamaları ile zaman temelli ve komplikasyon temelli modern sınıflandırma yaklaşımları ayrıntılı biçimde sunulmuştur. Klinik bulgular, Avrupa Kardiyoloji Derneği (European Society of Cardiology) ve Amerikan Kalp Derneği (American Heart Association) kılavuzları ile uyumlu tanısal algoritmalar ve görüntüleme stratejileri doğrultusunda değerlendirilmiştir. Medikal tedavi, cerrahi girişimler ve torasik endovasküler aort onarımı (TEVAR) güncel endikasyonlar doğrultusunda ele alınmıştır. Ayrıca TEVAR’ın erken müdahale stratejisindeki yeri, aortik yeniden şekillenme (aortic remodeling) süreci, uzun dönem prognoza etkisi ve izlem yaklaşımları ayrıntılı olarak değerlendirilmiştir. Bu bölüm, aortik hastalıkların acil yönetimi ve uzun dönem izlemine yönelik teorik ve pratik bilgileri bütüncül bir yaklaşımla sunmaktadır.
This chapter discusses aortic dissection and aortic aneurysms within the spectrum of acute aortic syndromes. The anatomical and histopathological features of the aortic wall are described in detail, and the mechanical, molecular, and cellular pathophysiological mechanisms involved in the development of dissection and aneurysm are reviewed in light of current literature. The Stanford and DeBakey classification systems, along with modern time-based and complication-based classification approaches, are comprehensively presented. Clinical findings, diagnostic algorithms, and imaging strategies are discussed in accordance with the guidelines of the European Society of Cardiology and the American Heart Association. Medical therapy, surgical interventions, and thoracic endovascular aortic repair (TEVAR) have been addressed in accordance with current indications. In addition, the role of TEVAR in early intervention strategies, the process of aortic remodeling, its impact on long-term prognosis, and follow-up strategies have been comprehensively evaluated. This chapter provides a comprehensive theoretical and practical overview of the emergency management and long-term follow-up of aortic diseases.
Referanslar
Isselbacher EM, Preventza O, Hamilton Black J 3rd, Augoustides JGT, Beck AW, Bolen MA, et al. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2022;146(24):e334-e482. doi:10.1161/CIR.0000000000001106
Czerny M, Schmidli J, Adler S, van den Berg JC, Bertoglio L, Carrel T, et al. Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic Surgery and the European Society for Vascular Surgery. Eur J Cardiothorac Surg. 2019;55(1):133-162. doi:10.1093/ejcts/ezy313
Riambau V, Böckler D, Brunkwall J, Cao P, Chiesa R, Coppi G, et al. Editor’s choice-Management of descending thoracic aorta diseases: clinical practice guidelines of the European Society for Vascular Surgery. Eur J Vasc Endovasc Surg. 2017;53(1):4-52. doi: 10.1016/j.ejvs.2016.06.005
Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018;39(9):739-749. doi:10.1093/eurheartj/ehx319
Evangelista A, Isselbacher EM, Bossone E, Gleason TG, Eusanio MD, Sechtem U, 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. doi:10.1161/CIRCULATIONAHA.117.031264
Harky A, Mason S, Othman A, Shaw M, Field M, McKane W, et al. Outcomes of acute type A aortic dissection repair: daytime versus nighttime. JTCVS Open. 2021; 7:12-20. doi: 10.1016/j.xjon.2021.04.017
Kordzadeh A, Rhodes KM. Type B aortic dissection management strategies: national survey, systematic review, and pooled clinician perceptions. J Vasc Dis. 2026;5(1):2. doi:10.3390/jvd5010002
Nienaber CA, Clough RE, Sakalihasan N, Suzuki T, Gibbs R, Mussa F, et al. Aortic dissection. Nat Rev Dis Primers. 2016; 2:16071. doi:10.1038/nrdp.2016.71
Flower L, Arrowsmith JE, Bewley J, Park D, Sturgess D, Grayson AD, et al. Management of acute aortic dissection in critical care. J Intensive Care Soc. 2023;24(4):409-418. doi:10.1177/17511437231162219
Lopes A, Mendes Pedro L, Gouveia e Melo R, Martins S, Rocha N, Sousa L, et al. Evolution of management of type B aortic dissection in a tertiary center. Rev Port Cardiol. 2023;42(7):603-612. doi: 10.1016/j.repc.2022.11.006
Lee D, Kim YW, Kim TY, Cho YH, Kim DK, Kim SJ, et al. Age-adjusted D-dimer in ruling out acute aortic syndrome. Emerg Med Int. 2022; 2022:6864756. doi:10.1155/2022/6864756
Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bown MJ, Brodmann M, Czerny M, et al. Editor’s choice-European Society for Vascular Surgery (ESVS) 2024 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms. Eur J Vasc Endovasc Surg. 2024;67(2):192-331. doi: 10.1016/j.ejvs.2023.11.002
Zhu J, Meganathan I, MacArthur R, Kassiri Z. Inflammation in abdominal aortic aneurysm: cause or comorbidity? Can J Cardiol. 2024;40(12):2378-2391. doi: 10.1016/j.cjca.2024.08.274
Pinard A, Jones GT, Milewicz DM. Genetics of thoracic and abdominal aortic diseases. Circ Res. 2019;124(4):588-606. doi:10.1161/CIRCRESAHA.118.312436
Milewicz DM, Ramirez F. Therapies for thoracic aortic aneurysms and acute aortic dissections. Arterioscler Thromb Vasc Biol. 2019;39(2):126-136. doi:10.1161/ATVBAHA.118.310956
Koch V, Biener M, Müller-Hennessen M, Vafaie M, Katus HA, Giannitsis E, et al. Diagnostic performance of D-dimer in predicting venous thromboembolism and acute aortic dissection. Eur Heart J Acute Cardiovasc Care. 2021;10(5):559-566. doi:10.1177/2048872620907322
Murillo H, Molvin L, Chin AS, Fleischmann D. Aortic dissection and other acute aortic syndromes: diagnostic imaging findings from acute to chronic progression. Radiographics. 2021;41(2):425-446. doi:10.1148/rg.2021200138
Ripley B, Scheidt MJ, Brook OR, Ghoshhajra BB, Kalva SP, Rybicki FJ, et al. ACR Appropriateness Criteria® thoracic aortic aneurysm or dissection-treatment planning and follow-up: 2024 update. J Am Coll Radiol. 2025;22(5 Suppl):S455-S478. doi:10.1016/j.jacr.2025.02.019
Le Huu A, Preventza O. Endovascular repair of acute type B thoracic aortic dissection. Ann Cardiothorac Surg. 2021;10(6):793-800. doi:10.21037/acs-2021-taes-26
Daily PO, Trueblood HW, Stinson EB, Wuerflein RD, Shumway NE. Management of acute aortic dissections. Ann Thorac Surg. 1970;10(3):237-247. doi:10.1016/S0003-4975(10)65594-4
Jiang X, Liu Y, Zou L, Wang H, Li Y, Xu Z, et al. Long-term outcomes of chronic type B aortic dissection treated by thoracic endovascular aortic repair. J Am Heart Assoc. 2023;12(1):e026914. doi:10.1161/JAHA.122.026914
Li D, Peng L, Wang Y, Zhao J, Yuan D, Zheng T. Predictors of false lumen thrombosis after thoracic endovascular aortic repair. J Thorac Cardiovasc Surg. 2020;160(2):360-367. doi: 10.1016/j.jtcvs.2019.07.091
Al-Tawil M, Chikhal R, Abdelhaliem A. Thoracic endovascular aortic repair for uncomplicated type B aortic dissection: optimal timing. J Card Surg. 2022;37(4):1002-1003. doi:10.1111/jocs.16191
Buja LM, Zhao B, Vela D, Segura A, Narula N. Pathobiology of aortic aneurysms and dissections: synthesis of recent investigations and evolving insights. JACC Adv. 2025;4(5):101682. doi:10.1016/j.jacadv.2025.101682
Xu C, Chen W, Nie X, Zhang Y, Li H, Wang J, et al. The innate immune axis drives aortic dissection pathogenesis through inflammation and presents novel therapeutic targets. Front Immunol. 2025; 16:1654622. doi:10.3389/fimmu.2025.1654622
Ostberg NP, Zafar MA, Ziganshin BA, Elefteriades JA. The genetics of thoracic aortic aneurysms and dissection: a clinical perspective. Biomolecules. 2020;10(2):182. doi:10.3390/biom10020182
Irqsusi M, Dong LA, Rodepeter FR, Zhang X, Chen Y, Li Q, et al. The role of matrix metalloproteinases in thoracic aortic disease: are they indicators for the pathogenesis of dissections? Biomedicines. 2024;12(3):619. doi:10.3390/biomedicines12030619
Nazerian P, Mueller C, Soeiro AM, Leidel BA, Salvadeo SAT, Giachino F, et al. Diagnostic accuracy of the aortic dissection detection risk score plus D-dimer for acute aortic syndromes: the ADvISED prospective multicenter study. Circulation. 2018;137(3):250-258. doi:10.1161/CIRCULATIONAHA.117.029457
Stelzmueller ME, Nolz R, Mahr S, Ehrlich MP, Holfeld J, Schoder M, et al. Thoracic endovascular repair for acute complicated type B aortic dissections. J Vasc Surg. 2019;69(2):318-326. doi: 10.1016/j.jvs.2018.05.234
Zhu B, Chen YE, Guo Y. Emerging mechanisms of abdominal aortic aneurysm. Curr Atheroscler Rep. 2026;28(1):17. doi:10.1007/s11883-026-01392-5
Corsini A, Pacini D, Lovato L, Leone A, Murana G, Di Marco L, et al. Long-term follow-up of patients with acute aortic syndromes: relevance of both aortic and non-aortic events. Eur J Vasc Endovasc Surg. 2018;56(2):200-208. doi: 10.1016/j.ejvs.2018.03.030
Writing Committee Members. ESC clinical practice update on acute aortic syndromes. Eur Heart J. 2023;44(5):398-410.
Referanslar
Isselbacher EM, Preventza O, Hamilton Black J 3rd, Augoustides JGT, Beck AW, Bolen MA, et al. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2022;146(24):e334-e482. doi:10.1161/CIR.0000000000001106
Czerny M, Schmidli J, Adler S, van den Berg JC, Bertoglio L, Carrel T, et al. Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic Surgery and the European Society for Vascular Surgery. Eur J Cardiothorac Surg. 2019;55(1):133-162. doi:10.1093/ejcts/ezy313
Riambau V, Böckler D, Brunkwall J, Cao P, Chiesa R, Coppi G, et al. Editor’s choice-Management of descending thoracic aorta diseases: clinical practice guidelines of the European Society for Vascular Surgery. Eur J Vasc Endovasc Surg. 2017;53(1):4-52. doi: 10.1016/j.ejvs.2016.06.005
Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018;39(9):739-749. doi:10.1093/eurheartj/ehx319
Evangelista A, Isselbacher EM, Bossone E, Gleason TG, Eusanio MD, Sechtem U, 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. doi:10.1161/CIRCULATIONAHA.117.031264
Harky A, Mason S, Othman A, Shaw M, Field M, McKane W, et al. Outcomes of acute type A aortic dissection repair: daytime versus nighttime. JTCVS Open. 2021; 7:12-20. doi: 10.1016/j.xjon.2021.04.017
Kordzadeh A, Rhodes KM. Type B aortic dissection management strategies: national survey, systematic review, and pooled clinician perceptions. J Vasc Dis. 2026;5(1):2. doi:10.3390/jvd5010002
Nienaber CA, Clough RE, Sakalihasan N, Suzuki T, Gibbs R, Mussa F, et al. Aortic dissection. Nat Rev Dis Primers. 2016; 2:16071. doi:10.1038/nrdp.2016.71
Flower L, Arrowsmith JE, Bewley J, Park D, Sturgess D, Grayson AD, et al. Management of acute aortic dissection in critical care. J Intensive Care Soc. 2023;24(4):409-418. doi:10.1177/17511437231162219
Lopes A, Mendes Pedro L, Gouveia e Melo R, Martins S, Rocha N, Sousa L, et al. Evolution of management of type B aortic dissection in a tertiary center. Rev Port Cardiol. 2023;42(7):603-612. doi: 10.1016/j.repc.2022.11.006
Lee D, Kim YW, Kim TY, Cho YH, Kim DK, Kim SJ, et al. Age-adjusted D-dimer in ruling out acute aortic syndrome. Emerg Med Int. 2022; 2022:6864756. doi:10.1155/2022/6864756
Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bown MJ, Brodmann M, Czerny M, et al. Editor’s choice-European Society for Vascular Surgery (ESVS) 2024 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms. Eur J Vasc Endovasc Surg. 2024;67(2):192-331. doi: 10.1016/j.ejvs.2023.11.002
Zhu J, Meganathan I, MacArthur R, Kassiri Z. Inflammation in abdominal aortic aneurysm: cause or comorbidity? Can J Cardiol. 2024;40(12):2378-2391. doi: 10.1016/j.cjca.2024.08.274
Pinard A, Jones GT, Milewicz DM. Genetics of thoracic and abdominal aortic diseases. Circ Res. 2019;124(4):588-606. doi:10.1161/CIRCRESAHA.118.312436
Milewicz DM, Ramirez F. Therapies for thoracic aortic aneurysms and acute aortic dissections. Arterioscler Thromb Vasc Biol. 2019;39(2):126-136. doi:10.1161/ATVBAHA.118.310956
Koch V, Biener M, Müller-Hennessen M, Vafaie M, Katus HA, Giannitsis E, et al. Diagnostic performance of D-dimer in predicting venous thromboembolism and acute aortic dissection. Eur Heart J Acute Cardiovasc Care. 2021;10(5):559-566. doi:10.1177/2048872620907322
Murillo H, Molvin L, Chin AS, Fleischmann D. Aortic dissection and other acute aortic syndromes: diagnostic imaging findings from acute to chronic progression. Radiographics. 2021;41(2):425-446. doi:10.1148/rg.2021200138
Ripley B, Scheidt MJ, Brook OR, Ghoshhajra BB, Kalva SP, Rybicki FJ, et al. ACR Appropriateness Criteria® thoracic aortic aneurysm or dissection-treatment planning and follow-up: 2024 update. J Am Coll Radiol. 2025;22(5 Suppl):S455-S478. doi:10.1016/j.jacr.2025.02.019
Le Huu A, Preventza O. Endovascular repair of acute type B thoracic aortic dissection. Ann Cardiothorac Surg. 2021;10(6):793-800. doi:10.21037/acs-2021-taes-26
Daily PO, Trueblood HW, Stinson EB, Wuerflein RD, Shumway NE. Management of acute aortic dissections. Ann Thorac Surg. 1970;10(3):237-247. doi:10.1016/S0003-4975(10)65594-4
Jiang X, Liu Y, Zou L, Wang H, Li Y, Xu Z, et al. Long-term outcomes of chronic type B aortic dissection treated by thoracic endovascular aortic repair. J Am Heart Assoc. 2023;12(1):e026914. doi:10.1161/JAHA.122.026914
Li D, Peng L, Wang Y, Zhao J, Yuan D, Zheng T. Predictors of false lumen thrombosis after thoracic endovascular aortic repair. J Thorac Cardiovasc Surg. 2020;160(2):360-367. doi: 10.1016/j.jtcvs.2019.07.091
Al-Tawil M, Chikhal R, Abdelhaliem A. Thoracic endovascular aortic repair for uncomplicated type B aortic dissection: optimal timing. J Card Surg. 2022;37(4):1002-1003. doi:10.1111/jocs.16191
Buja LM, Zhao B, Vela D, Segura A, Narula N. Pathobiology of aortic aneurysms and dissections: synthesis of recent investigations and evolving insights. JACC Adv. 2025;4(5):101682. doi:10.1016/j.jacadv.2025.101682
Xu C, Chen W, Nie X, Zhang Y, Li H, Wang J, et al. The innate immune axis drives aortic dissection pathogenesis through inflammation and presents novel therapeutic targets. Front Immunol. 2025; 16:1654622. doi:10.3389/fimmu.2025.1654622
Ostberg NP, Zafar MA, Ziganshin BA, Elefteriades JA. The genetics of thoracic aortic aneurysms and dissection: a clinical perspective. Biomolecules. 2020;10(2):182. doi:10.3390/biom10020182
Irqsusi M, Dong LA, Rodepeter FR, Zhang X, Chen Y, Li Q, et al. The role of matrix metalloproteinases in thoracic aortic disease: are they indicators for the pathogenesis of dissections? Biomedicines. 2024;12(3):619. doi:10.3390/biomedicines12030619
Nazerian P, Mueller C, Soeiro AM, Leidel BA, Salvadeo SAT, Giachino F, et al. Diagnostic accuracy of the aortic dissection detection risk score plus D-dimer for acute aortic syndromes: the ADvISED prospective multicenter study. Circulation. 2018;137(3):250-258. doi:10.1161/CIRCULATIONAHA.117.029457
Stelzmueller ME, Nolz R, Mahr S, Ehrlich MP, Holfeld J, Schoder M, et al. Thoracic endovascular repair for acute complicated type B aortic dissections. J Vasc Surg. 2019;69(2):318-326. doi: 10.1016/j.jvs.2018.05.234
Zhu B, Chen YE, Guo Y. Emerging mechanisms of abdominal aortic aneurysm. Curr Atheroscler Rep. 2026;28(1):17. doi:10.1007/s11883-026-01392-5
Corsini A, Pacini D, Lovato L, Leone A, Murana G, Di Marco L, et al. Long-term follow-up of patients with acute aortic syndromes: relevance of both aortic and non-aortic events. Eur J Vasc Endovasc Surg. 2018;56(2):200-208. doi: 10.1016/j.ejvs.2018.03.030
Writing Committee Members. ESC clinical practice update on acute aortic syndromes. Eur Heart J. 2023;44(5):398-410.
