Aortic Dissection

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Aortic Dissection
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Epidemiology

• gt2000 cases/year
• 2-3 X incidence of ruptured AAA
• Catastrophic if overlooked
• Age 60 50-70, 87 gt 40
• Men 31

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Aortic Anatomy/Physiology

• Cellular Layers
• Intima
• endothelium
• Media
• Adventitia

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Aortic Pathophysiology

• The initiating event is either a primary intimal
  tear with dissection into the media or a medial
  hemorrhage that dissects into the intima.

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Risk Factors

• HTN
• Ehlers-Danlos/ Marfans
• Bicuspid Aortic Valve
• Trauma
• Coarctation
• Pregnancy
• Takayasus Arteritis

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Classification - Anatomic
DeBakey Type I-III
Stanford Type A, B
Figure Braunwauld, Cardiovascular Disease, 1996
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Symptoms

• Sudden onset of severe pain
• Tearing
• Radiates to the interscapular region
• Typically migrates with propagation
• Most severe at onset
• Diaphoresis
• Syncope
• Dyspnea
• Weakness

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Clinical Manifestations

• Hypertension or Hypotension
• Loss of Pulses
• Aortic Regurgitation
• Pulmonary Edema
• Neurologic Findings? hemiplegia, paraplegia
• Bowel Ischemia
• Hematuria
• Acute-MI
• Horners Syndrome
• Hemopericardium Tamponade

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EKG

• The EKG is most useful in distinguishing Aortic
  Dissection from an Acute MI.
• Rarely the dissection involves the ostium of the
  RCA or the LCA resulting in an acute-MI

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Chest X-Ray

• Wide Mediastinum
• Left Sided Pleural Effusion
• Abnormal Appearance of the Aortic Knob

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CT Scan

• Better than 90 sensitive and Specific

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MRI

• More sensitive and specific than CT

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ECHO

• TTE limited
• AI, Effusion
• TEE
• Sens 98 Spec 95
• Portable
• Use in ER, unstable pt

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Treatment

• Pain control (morphine)
• ICU, Art line , UOP
• Anti impulse reduce dP/dt, blood pressure
• Surgical Indications
• Complication recognition/management

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Surgical Indications

• Ascending dissection
• Descending dissection
• organ/limb ischemia, pain
• Rupture, expansion
• Open false lumen, high communication, no thrombus