Aortic Dissection

Last Updated on by frcemuser

Risk factors

  • hypertension
  • smoking
  • pre-existing aortic diseases or aortic valve disease, family history of aortic diseases
  • intravenous drugs (eg, cocaine and amfetamines)
  • Inherited risks include Marfan’s syndrome, Ehlers-Danlos syndrome

Classification

The Stanford Classification in common use classifies the dissections into type A and type B:

  • Type A involves ascending aorta (DeBakey types I and II).
  • Type B does not involve the ascending aorta (DeBakey type III).

The DeBakey Classification classifies the dissections into:

  • Type I: aorta, aortic arch, and descending aorta.
  • Type II: ascending aorta only.
  • Type III: descending aorta distal to left subclavian.

Presentation

  • aortic dissection may present with chest pain, aortic regurgitation, myocardial ischaemia, congestive heart failure, pleural effusions, syncope, neurological symptoms (eg, acute paraplegia, upper or lower limb ischaemic neuropathy), mesenteric ischaemia and acute kidney injury
    • Angina due to involvement of the coronary arteries.
    • Paraplegia due to involvement of the spinal arteries.
    • Limb ischaemia due to distal aortic involvement.
    • Neurological deficit due to carotid artery involvement.

Imaging

  • CT scanning may be used to confirm the diagnosis
  • CXR
    • Widened mediastinum (56-63%), abnormal aortic contour (48%), aortic knuckle double calcium sign >5mm (14%), pleural effusion (L>R), tracheal shift, left apical cap, deviated NGT. ‘Normal’ in 11-16%.

Management 

  • Adequate analgesia – eg, morphine.
  • Hypertension must be managed aggressively in all cases to reduce further damage. The aim is a systolic pressure of between 100 and 120 mm Hg.
  • Intravenous beta-blockers are usually employed, as they also reduce the force of ventricular contraction. If vasodilators are used they should be combined with beta-blockers.

Surgery

  • For acute type A (types I and II) dissection, surgery aims to prevent aortic rupture and pericardial tamponade and to relieve aortic regurgitation
  • For type B aortic dissection, thoracic endovascular aortic repair (TEVAR) in addition to optimal medical treatment

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