Aortic Dissection
(Schwartz’s 11th Ed.)
Pathology and Classification
 Most common catastrophic
event involving the aorta
 Progressive separation of aortic
wall layers that usually occurs
after a tear forms in the intima
and inner media
 2 channels formed
 True lumen; original lumen lined
by intima
 False lumen; newly formed
channel w/in the layers of the
media
 Dissecting membrane – 
separates the two lumens
 Additional tears that allow
communication between the two
channels are called reentry
sites
 Proximal extension/retrograde
dissection – proximal separation
 Anatomic consequences
 Outer wall of false lumen is
extremely thin, inflamed, and
fragile  prone to
expansion/rupture due to
hemodynamic stress
 Expanding false lumen can
compress the true lumen;
causes malperfusion syndrome
by interfering w/ blood flow in
the aorta or any of its branch
vessels
 when the separation occurs in
the aortic root  aortic valve
commissures can become
unhinged; results in acute
valvular regurgitation
 Dissection vs. aneurysm
 Separate entities; often co-exist
and are mutual risk factors
 Subsequent progressive dilation
Causes and Clinical Hx
 Most px (90%) die w/in 3 mo.
w/o proper modern medical or
surgical tx, mostly from rupture
 Specific cause unknown
 Risk factors
 Any condition that weakens the
aortic wall
 Common general cardiovascular
risk factors
(smoking, HPN,
atherosclerosis, and
hypercholesterolemia)
Px w/ heritable forms of
aortopathy, aortitis, bicuspid
aortic valve, or preexisting
medial degenerative disease;
thoracic aneurysm
 Aortic injury during cardiac
catheterization, surgery, or
endovascular repair  
iatrogenic dissection
 Cocaine, amphetamine use;
severe emotional stress,
extreme physical exertion
Clinical Manifestations Diagnostic Evaluation Treatment
 Onset  CT – contrast-enhanced;  Initial treatment and
 Severe chest/back pain; tearing; diagnostic feature: double- management
migrates distally lumen aorta - Blood pressure control
 Location of pain indicates  MRA  IV Beta-blockers, direct
segment involved  Echocardiography – vasodilators, calcium
 Anterior chest – Transesophageal channel blockers, ACEI
ascending aorta echocardiography  Esmolol
 Back and abdomen –  Labetalol
descending and  Nitroprusside
thoracoabdominal  Enalapril
 Potential complications - Pain control
 Cardiac ischemia or tamponade  IV opiates
– coronary artery  Morphine
 Stroke – brachiocephalic  Fentanyl
 Paraplegia/paraparesis –  Ascending aortic dissection
intercostal - Emergent graft replacement
 Mesenteric ischemia – superior of the ascending aorta
mesenteric  Descending aortic dissection
 Kidney failure – renal -
Limb ischemia/loss of motor
function – brachial or femoral
 Regurgitation – due to injury of
aortic valve
 Severity varies w/ degree of
commissural disruption; partial
separation of one commissure
to full separation of all 3
commissures and complete
prolapse of valve into left
ventricle  severe acute heart
failure
 May report rapidly worsening
dyspnea
 Ascending dissections
 Can extend to coronary arteries/
shear coronary ostia off the true
lumen  acute coronary
occlusion; often involvers R.
Coronary artery
 Can cause myocardial infarction
 Thin and inflamed outer wall of
 of outer aortic wall  aneurysm dissected ascending aorta 
 Degenerative aneurysm; serosanguineous pericardial
ongoing deterioration of aortic effusion  accumulation 
wall  superimposed tamponade
dissection; dissecting aneurysm  Signs – jugular venous
distention, muffled heart tones,
Classification pulsus paradoxus, low-voltage
 According to location and ECG tracings
chronicity  As dissection progresses
 Location  Any aortic branch can get
 According to anatomic location involved; compromised blood
and extent flow and ischemic complications
 DeBakey and Stanford (i.e. malperfusion)
classification; Stanford does not  Acute stroke, paraplegia,
distinguish between px w/ hepatic failure, bowel infarction,
isolated ascending aortic renal failure, or a threatened
dissection and px w/ dissection ischemic limb
involving the entire aorta
 Px w/ isolated ascending aortic
dissection usually undergo
emergent operation as do px w/
dissection involving both
ascending and descending
aortic segments
 Px w/ isolated descending
thoracic and abdominal aortic
dissection are typically treated
medically
 Chronicity
 Acute – first 14 days after initial
tear
 Subacute – days 15 to 60
 Chronic – after 14 days
 Variants
 Intramural hematoma
 Collection of blood w/in
the aortic wall, w/o an
intimal tear; believed to
be due to rupture of
vasa vasorum w/in
media
 Can result in a
secondary intimal tear
that eventually leads to
dissection
 Penetrating aortic ulcer
 Disrupted
atherosclerotic plaque
that projects into the
aortic wall, associated
w/ surrounding
hematoma
 Can penetrate the aortic
wall  rupture or
dissection