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Les syndromes aortiques aigus [Acute aortic syndromes]
Sang Thrombose Vaisseaux
The acute aortic syndromes comprise three entities: aortic dissection, intramural haematoma and penetrating atherosclerotic ulcer. The life-threatening nature of these conditions requires that diagnosis and treatment be rapid with the most reliable and least invasive technique possible. Imaging methods are essential with several objectives; accurate description of the lesions, topographical classification, investigation of the extent of the lesions to the supraaortic and visceral arteries or of involvement of adjacent structures such as the pericardium, the pleural or mediastinal cavities. These extensive investigations provide an evaluation of the severity and potential for progression of the lesions and a guide to treatment. The CT scan is the best method of investigation in an emergency but it does report the state of the aortic valve. Echocardiography has the advantage of being widely available and can be performed at the bedside in the intensive care unit but it is not always informative. However, this technique allows evaluation of left ventricular function, exclusion of the diagnosis of cardiac failure or pericardial effusion. In practice, the two investigations are often complementary. Treatment and surveillance in the intensive care unit are essential in all cases. Besides medical therapy, schematically, ascending aortic lesions require emergency surgery as a rule, sometimes associated with an endovascular procedure especially in cases with abnormal perfusion of viscera. In type B aortic dissection, surgery and endovascular procedures are reserved for complications, principally rupture and visceral ischaemia. In these cases, endovascular techniques have progressed because of their better tolerance. Exclusion of the proximal intimal tear by a stent-graft depressurises the false lumen and predisposes to its thrombosis. Remodelling with reduction of the aortic diameter is observed with reperfusion of the distal vessels. Endovascular fenestration is reserved for problems of perfusion due to a dynamic mechanism. The principle is to create a wide orifice between the true and false lumens in order to reduce pressure in the false lumen. The implantation of bare stents may be useful in the arteries of viscera with ischaemia by a static mechanism. In conclusion, aortic dissection may be treated effectively by endovascular techniques, either alone or as a complement to surgery of the ascending aorta
aortic dissection, intramural hematoma, aortic ulcere, stent-graft, stent, fenestration, acute aortic syndrome
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