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AORTIC DISSECTION
Aortic Dissection Medical Editor: Donya Moslemzadeh
OUTLINE I) OVERVIEW
Vasa vasorum
small blood vessels supply oxygen and nutrients to
the outer layers of the arterial wall
(2) Trauma
Iatrogenic Injuries
o Catheterization
o Valve Repairs
(3) Vasculitis
= Inflammation of the blood Vessel wall
Triggers :
o Tertiary Syphilis
Inflammation of the Vasa vasorum caused by
Treponema pallidum→↓Blood Supply to the
arterial walls → Cystic Medial Degeneration of the
Tunica Media → Weak wall →↑ Risk of Dissection
o Takayasu Arthritis
Inflammatory granulomas deposit in the vessel
walls → Medial Degeneration of the Tunica Media
→ Weak wall →↑ Risk of Dissection
Age < 50
Usually, Aorta is Involved
Less Facial and Ocular involvement compared to
Giant cell. Arthritis
(1) Connective Tissue Diseases A narrowing of the descending aorta (after aortic arch), at
the level of Left Subclavian artery , near Ductus
Defect in the connective tissues of the blood vessels Arteriosus
→Weak vessel wall → ↑ Risk of having a tear, ↑ Risk Mechanism: Narrowing cause a lot of resistance →
Aneurysm → ↑ Risk of Dissection ↑Blood pressure proximal to the affected area → HTN →
→↑ Risk Aortic Dissection , ↑ Risk Aneurysm
Connective tissues of the blood vessels Figure 1 Patients with Coarctation of Aorta probably have
o Subendothelial Layer o History of Turner Syndrome
o Elastic Laminas o Associated Bicuspid aortic Valve
o Tunica Externa
Aneurysm
True Aneurysm
o abnormal dilation of an artery due to a weakened
vessel wall, ≥50% dilation of all 3 layers of aorta
False Aneurysm
o external hematomas with a persistent
communication to a leaking artery, rupture within
adventitia
Aneurysm → ↑ Risk of Dissection
Dissection → ↑Risk of Aneurysm
Marfan Syndrome
Etiology
o Mutation of Fibrillin Gene → ↓Elasticity of the vessel
walls→ ↑ Risk Aneurysm and ↑ Risk of Dissection
Clinical Features
o Cardiovascular Disorders: mitral valve prolapse, aortic
aneurysm, and dissection
o Musculoskeletal Disorders: tall stature with
disproportionately long extremities, joint hypermobility
o Eyes Disorders: subluxation of the lens of the eye
Ehlers-Danlos Syndrome(EDS)
Etiology
o Mutation of Collagen Gene→ ↓Resilience of the blood
vessels →↑ Risk Aneurysm and ↑ Risk of Dissection
Clinical Features
o Cardiovascular Disorders: mitral valve prolapse, aortic
aneurysm, and dissection
o Musculoskeletal Disorders: Joint Hypermobility
o Skin Disorders : Skin hyperextensibility, Easy
Bleeding , Tendency to bruise easily
Brachiocephalic, Syncope
Occlusion →↓ blood flow to
common carotid, Cerebral Vascular incidents (Stroke)
the brain
or left subclavian arteries
↓Urine output
Dynamic Obstruction and Acute kidney Injury
Renal artery Malperfusion of the Renal o ↑Creatinine
Artery o ↑BUN
o ↓GFR
Occlusion Anterior Spinal Artery Syndrome
o Paraplegia of lower extremities
Artery of Adamkiewicz o Loss of Sensations
o Incontinence
Pulselessness of LLE
↓BP compared to RLE
If Occlusion of the Left Weakness
Common Iliac artery Acute Limb Ischemia
Common iliac artery o Pulselessness
→↓Blood flow to the Left
Lower Extremities LLE o Pain
o Losing color (Pallor)
o Weak muscle →Paralysis
o Cold (Poikilothermia
Cannot be
performed at
Gold standard: Very the bedside
CTA high sensitivity and Radiation
specificity exposure
Operative Planning Contrast
Figure 11. Aortic Dissection CTA.
exposure
Cannot be
Very high sensitivity performed at
MRA and specificity the bedside
No radiation exposure Time
Consuming
VI) TREATMENT
Type of Dissection Determination
(B) MEDICAL TREATMENT
Aortic dissection classification systems
o The DeBakey System (1) Hypotensive Patients
o The Stanford System (Preferred) Goal → Mean Arterial Pressure ≥70mmhg
Stanford Classification IV Fluid
o Stanford A o IV Fluid →↑ Blood Volume →↑Blood Pressure
Involves Ascending Aorta Vasopressor
Emergency → Surgical Therapy o →↑SVR →↑Blood Pressure
o Stanford B o Norepinephrine
Beyond Left Subclavian Artery → Involves o Phenylephrine (Pure Alpha-1 vasoconstrictor)
Descending Aorta
Medical Therapy BUT you may need Surgical Blood Transfusion
Intervention o →↑ Blood Volume →↑Blood Pressure
Complications → may need Surgery Evaluate 3 Scenarios and fix them
• Medical Treatment Failure o Rupture→ repair the rupture
• Rupture o Cardiac Tamponade → Pericardial Fluid Drainage
• Propagation of dissection o Severe Aortic insufficiency → Valve Repair
• Expanding intramural Hematoma
(2) Hypertensive Patients
(A) SURGICAL TREATMENT Goal:
Open Surgery → replacement of the dissection with a o Systolic Blood Pressure 100-120mmhg
polyester graft implantation o Heart Rate < 60bpm
a. Type A Dissections
Endovascular Stent Placement Beta Blockers (Alpha and Beta blocker activity)
a. Type B Dissections o Esmolol
o Labetalol
o Mechanism:
Blocking Beta receptors on AV/SA nodes→ ↓Heart
Rate
Blocking Alpha-1 → Vasodilation → ↓SVR → ↓BP
o Beta Blockers are given first to prevent Reflex
Tachycardia
Vasodilators
o Vasodilators → Low Blood Pressure → Stimulate
Cardiac Acceleratory Center in the brain →↑Heart
rate and contractility (Reflex tachycardia)
Figure 12. Aortic Dissection Surgical Treatment. o Sodium Nitroprusside
Vasodilation → ↓SVR → ↓BP
VII) APPENDIX
IX) REFRENCES
● AMBOSS: medical knowledge platform for doctors and students.
(n.d.). Amboss. Retrieved 2021, from https://www.amboss.com/us/
● UpToDate: Evidence-based Clinical Decision Support. (n.d.).
UpToDate.Com. Retrieved 2021, from
https://www.wolterskluwer.com/en/solutions/uptodate
● Le, T., Bhushan, V., & Sochat, M. (2021). First Aid for the
USMLE Step 1 2021, Thirty First Edition (31st ed.). McGraw-Hill
Education / Medical.
● Gabriel, D. (2019). USMLE Step 2 CK: A Student-to-student
Guide (Clinical Knowledge) (10th ed.). Independently published.
● Papadakis, M., McPhee, S., & Rabow, M. (2019). CURRENT
Medical Diagnosis and Treatment 2020 (59th ed.). McGraw-Hill
Education / Medical.