İnen torasik aorta diseksiyonu

Özet

İnen torasik aortada diseksiyon çoğunlukla sol subklavyen arter çıkışının distalinde başlar; gerçek lümen, yalancı lümen ve dal damar ilişkisi tüm aorta boyunca haritalanmalıdır. BTA giriş yırtığını, yalancı lümen açıklığını veya trombozunu ve torakoabdominal yayılımı gösterir. Sol renal, mezenterik ya da ekstremite damarlarının etkilenmesi organ malperfüzyonuna yol açabilir. Rüptür, hemotoraks ve dal damar tıkanıklığının atlanması acil risk sınıflamasını bozar.

Okuma sırası

1. Proksimal inen aorta. Sol subklavyen çıkışının hemen distalindeki aortayı bulun ve aksiyel kesitlerde lümen içinde ikinci bir kanal oluşturan membranı arayın.
2. Yalancı lümen. Flebin iki tarafını tüm toraks boyunca takip edin; keskin açılı gaga veya ince medya şeritleri bulunan kanalı yalancı lümen olarak tanımlayın.
3. Yalancı lümen trombozu. Kontrastlanmayan kanal bölümünün uzunluğunu ve devamında tekrar dolup dolmadığını izleyerek parsiyel trombozu belirleyin.
4. Dal damarlar ve rüptür alanları. İncelemeyi diyafram altına sürdürün; çölyak, mezenterik ve renal dalların çıkışını, distal organ kontrastlanmasını ve plevral/periaortik kanı kontrol edin.

Faz ve pencere

Kontrastsız

İntimal kalsifikasyonun yer değiştirmesi, duvar içi kanama veya tromboze yalancı lümen görülebilir; kontrastsız seri damar açıklığını ve dal damar perfüzyonunu göstermez.

BTA tanısal

Sol subklavyen distalinden başlayarak torasik ve abdominal aortadaki flep, gerçek/yalancı lümen dolumu, tromboz, giriş-yeniden giriş açıklıkları, dal damar çıkışları ve rüptür işaretleri değerlendirilir.

Önerilen pencereler: Anjiyo (G 600 / M 150), Mediasten (G 350 / M 50), Batın (G 400 / M 50).

BT bulguları

• İntimal flep — inen aorta kontrast kolonunu gerçek ve yalancı kanallara ayırır; aksiyel kesitlerde spiral seyir gösterebilir.
• Yalancı lümen trombozu — kanalın bir bölümünde kontrast dolmaması; patent ve tromboze segmentler birlikte bulunabilir.
• Gaga işareti — yalancı lümenin dış duvara dar açıyla uzanan kama biçimli başlangıç alanı.
• Gerçek lümen basısı — sıkışmış, hilal biçimli gerçek kanalın dal damar çıkışlarını veya distal akımı daraltması.
• Dal damar ilişkisi — çölyak trunkus, üst mezenterik, renal ve iliak arterlerin hangi lümenden beslendiği ve ostiumlarının açık olup olmadığı.
• Torakoabdominal uzanım — flebin diyafram altına ve abdominal aortaya devamı; tüm aortanın kesintisiz izlenmesi gerekir.
• Rüptür bulguları — periaortik hematom, sol plevral kan, kontrast dışına kaçış veya kontur bütünlüğü kaybı.

Ölçütler ve sınıflamalar

Stanford sınıflaması

Stanford tip B çıkan aortayı içermez; diseksiyon arkusa uzanabilir. Çıkan aorta korunurken diseksiyon arkusla sınırlıysa veya inen aortadan arkusa retrograd uzanıp çıkan aortaya ulaşmıyorsa 2024 ESC/EACTS non-A/non-B olarak sınıflar. Çıkan aortaya uzanım varsa tip A kabul edilir.

DeBakey sınıflaması

Tip III inen aortada başlar; IIIa torasik segmentte sınırlı, IIIb diyafram altına uzanan diseksiyonu tanımlar.

2024 ESC Type–Entry–Malperfusion (TEM) çerçevesi

Akut aortik sendromu hastalık tipi (Tip A, Tip B veya non-A/non-B), primer intimal giriş yeri (Entry) ve malperfüzyon durumunu (Malperfusion) birlikte tanımlar. Kök/çıkan aorta tutulumu ile proksimal ve distal yayılım ayrıca anatomik olarak gösterilmelidir.

Normalde

Normal inen aortada tek, düzgün kontrastlı lümen vardır; duvar çevresindeki intimal kalsifikasyon lümene doğru ayrışmaz ve dal damar ostiumları tek kanaldan çıkar. Aynı seviyedeki normal torasik aorta ile karşılaştırırken flebin lümenleri bölüp bölmediğini ve yalancı kanalın hangi dal damarları beslediğini izleyin.

Ayırıcı tanı

Aortik intramural hematom

kontrastsız seride hiperdens duvar kalınlaşması yapar; patent flep ve çift lümen yoktur.

Mural trombüs

aterosklerotik duvara bitişik eksantrik dolum defektidir; diseksiyon flebiyle ayrılmış ikinci kanal bulunmaz.

Penetran aterosklerotik ülser

plak içinden dış duvara doğru uzanan fokal kontrast krateridir; uzunlamasına iki kanal oluşturması beklenmez.

Aortik psödoanevrizma

intimal yırtık veya travma sonucu oluşan, diseksiyon flebiyle tam kanal oluşturmayan lokalize sakküler kanama kavitasyonudur.

Tuzaklar

• Yalancı lümen kontrastı gerçek lümenden geç gelebilir; tek erken kesitte kontrastsız kanalı tromboz sanmayın, tüm BTA hacmini izleyin.
• Dal damar ostiumunun kısmi flep ilişkisi statik BT'de akım yetersizliğini kanıtlamaz; damar açıklığını ve distal organ kontrastlanmasını birlikte raporlayın.
• Yalancı lümenin tromboze bölümü IMH'yi taklit edebilir; başka seviyelerde patent yalancı kanal, giriş yırtığı veya değişen duvar konturunu arayın.

Kendini dene

1. İnen aortada flep iki kanalı ayırıyor; yalancı kanal kısmen dolu, kısmen kontrastsız. Bu görünüm neyi gösterir?

   • Parsiyel yalancı lümen trombozu
   • Aortik intramural hematom
   • Penetran ülser
   • Aortit
   Cevabı göster

   Parsiyel yalancı lümen trombozu. Flep ile ayrılmış kanalın bir kesimde kontrastlanıp başka kesimde dolmaması parsiyel tromboze diseksiyon yalancı lümenini gösterir. IMH'de tipik ayrışmış flep yoktur; ülser fokal kraterdir, aortit duvar inflamasyonu yapar.

2. Flep çölyak trunkus ostiumuna uzanıyor; karaciğer ve dalak kontrastlanması korunmuş. BT'den hangi çıkarım doğrudur?

   • Dal damar ilişkisi var, iskemi kanıtı yok
   • Çölyak arter tamamen tıkalı
   • Karaciğer infarktı kesin
   • Aortik rüptür gelişmiştir
   Cevabı göster

   Dal damar ilişkisi var, iskemi kanıtı yok. Çölyak trunkus abdominal aortadan çıktığı için flebin bu ostiuma ulaşması abdominal aorta tutulumunu da gösterir. Organ kontrastlanması korunmuş; ostiumla anatomik ilişki tek başına malperfüzyon kanıtı değildir. Tam oklüzyon, infarkt veya rüptür tarif edilmemiştir.

İlgili konular

• Çıkan aorta diseksiyonu
• Non-A/non-B diseksiyon
• Aortik intramural hematom
• Penetran aterosklerotik ülser

Kaynaklar

Bu sayfadaki 45 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 1 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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