Him ORIGINAL CONTRIBUTION The International Registry of Acute Aortic Dissection (IRAD) New Insights Into an Old Disease MB ber, MD. rie M, Isselhacher, MD David Bruckman, MS Peter G. Hag Ihristoph A. Nie Dean J. Karavite Pamela 1. Russian, BS Arturo Evangelista, MD Rosella Fattori, MD Andrew , Moore, MD Joseph F. Malouf, MD da A. Pape, MD Tharlene Gaca, RN MD Udo Secht Lenferink, MD Hans Josef Deutsch, MD. Holger Diedrichs, MD. Jose Marcos y Robl Alfredo Llovet, MD Dan Gilon, MD K. Das MD E G Michael Deeb, MD Kim A. Fagle, MD. MD Context Acute aortic dissection is a life-threatening medical emergency associated with high rates of morbidity and mortality. Data are limited regarding the effect of recent imaging and therapeutic advances on patient care and outcomes in this, setting Objective To assess the presentation, management, and outcomes of acute aortic dissection, Design Case series with patients enrolled between January 1996 and December 1998. Data were collected at presentation and by physician review of hospital records, Setting The International Registry of Acute Aortic Dissection, consisting of 12 inter- rational referral centers. Participants total of 464 patients (mean age, 63 years; 65.3% male), 623% of whom had type A dissection. ‘Main Outcome Measures Presenting history, physical findings, management, and ‘mortality, as assessed by history and physician review of hospital records. Results While sudden onset of severe sharp pain was the single most common pre- senting complaint, the clinical presentation was diverse, Clasic physical findings such as aoc regugtaton and pus deft were noted in only 3.6% and 15.1% of pa tients, respectively, and initial chest radiograph and electrocardiogram were fre- quently not helpful (no abnormalities were noted in 12.4% and 31.3% of patients, respectively). Computed tomography was the intial imaging modality used in 61.1% Overall in-hospital mortality was 27.4%. Mortality of patients with type A dissection ‘managed surgicaly was 26%; among those not receiving surgery (typically because of advanced age and comorbidity), mortality was 58%. Mortality of patients with type B dissection treated medically was 10.7%. Surgery was performed in 20% of patients, with type B dissection; mortality in this group was 31.496, Conclusions Acute aortic dissection presents with a wide range of manifestations, and classic findings are often absent. A high clinical index of suspicion is necessary. Despite recent advances, in-hospital mortality rates remain high. Our data support the need for continued improvement in prevention, diagnosis, and management of acute aortic dissection, JAMA, 2000283:897-502 ww jamacom ‘Author Afiations:Universy of Michigan, Aan A= bor tre Hagan, Das, Amstong” Deeb, ad Engle, Mase ruck anlar, dM ura Me ‘Seuss Crea Hosp ose (sehen ‘niversty of Masachsetis, Worcester Dr Pape and soca Horta Gener Unies Hebron, aceon (Or range and Hosa Y2de Oct, Madi Ors Macs y Robes and Lovet, Spi: Uni- (Drs Deutsch an Desc), Gemary: and Hadassah vetsty Hosp Ona, Baogra ay OrFatonlUn- Univers Hospeal rsa, bal Dr Gir) Vest fT, Tajo Japan(OrSuuh): Mayo Cin. Canesponding autor anaRepnts: KA Ease MO, octet Mn (Dm Oh Moore, and Meu; Un Dison of Cadlogy,Departmet of ntl Med versty Hosptal Ependor, Hamburg (Dr Neb), ce, Univrsty of Mlhgan Med Center, 1500 € ovet Sou ieakenhaus Sutlat DrsSchem and Masial Center Dr, An Abr, Ml 8103-0865 (e- Lenfrnt, ana Unvesiy of Cologne, Cologne mar keagedumiche) (©2000 American Medical Association, All rights reserved, JAMA, Febuary 16,2000 23, No.7 8977 Downloaded From: on 07/04/2018NEW INSIGHTS INTO ACUTE AORTIC DISSECTION (On 25 October 1760 George I, then 76, rose at hisnormal hour of 9, called as usual for his chocolate, and repaired othe closest. The German valet de chambre heard a nose ‘memorably described as louder than the royal ‘wind, and then a groan; he ran in an found the King ying on te lor, having cut his face infalling Mr- Andrews, surgeon of the howse- hold, was alle and bed his Majesty but in Ain, ann sgn of hfe was abserved fom the tie of hs fll At necropsy the nextday Dr Nicholls, physician to his late Majesty, found the pericandium distended witha pnt of co- ‘aula blood, probably roman orifice inthe right ventricle, and a transverse issue on the inner side ofthe ascending arta 373 em long, through which blood had recently passedin ts extemal cat to forma raised ecciymosis, this npearance being interpreted as an incipient aneurysm ofthe aorta Disease i very old, and nothing about it has changed. tis we who change as we learn to recognize what was formerly imperceptible “Jean Martin Charcot CUTE AORTIC DISSECTION 15 A challenging clinical emer gency frst deseribed by Mor- gagni more than 200 years, ago. 1958, Hirst etal? reviewed 505 patients with the condition, highlight- ing the high mortality rate and the in- frequency of antemortem diagnosis. Prior to the introduction of eardiopul- monary bypass in the mid 1950s, sur- gical options were severely limited." Since Debakey first reported surgical re- pair ofathoracie aortic aneurysm, man- agement techniques have steadily ad- vanced.” Recently, percutaneous fenestration and/or stent placement hhave been used in select patients." Similarly, diagnostic imaging modalic ties, including computed tomogra- phy, transesophageal echoeardiogra- phy, and magnetic resonance imaging, have been developed and are widely available 2° Aortic dissection is the most com- mon acute aortic condition requiring urgent surgical therapy.2°” Separa- lion of the layers within the aortic wall, characterizes dissection. Blood enters is space with further propagation of the dissection. Typi- cally, For more tears in the intimal layer allow communication between the 2hu- the intima-mes mens. Intramural hematoma without an intimal ear isa distinct pathological le- 898 JAMA, February 16,2000 Vo 283, No.7 Downloaded From: on 07/04/2018 sion that is being observed with in- creasing frequency. Presenting fe: tures are similar, and progression to dissection may occur.” While the ini- tating event is unknown, most pa- dents have a structural abnormality of the arterial wall and/or systemic hyper- Classification of aortic dissection is based on anatomical location and time from onset. Stanford type A dissections involve the ascending aorta and type B dissections oceur distal to the left sub- clavian artery. The 14-day period af- teronset has been designated the acute phase, because morbidity and mortal- ity rates are highest and surviving pa- tients typically stabilizeduring thistime. [Because presenting clinical features are diverse and serious complications occur rapidly, antemortem diagnosis hhas proven difficult." One would predict that the advent of modern im- ‘aging combined with progress in both surgical and nonsurgical therapy should result in improved outcomes. Little is known about the effect of these devel- opments. Therefore, Th tional Registry of Acute Aortic Disse tion (IRAD) was established in 1996, enrolling patients at large referral cen- ters, to assess the current presenta don, management, and outcomes of acute aortic dissection. METHODS: Patient Selection Twelve large referral centers in 6 coun- ries are participating in the registry. All patients with acute aortic dissection were enrolled beginning January 1 1096, Patients were identified at pre- sentation or by searching hospital dis- charge diagnosis records and surgical and echocardiography laboratory da- tabases. Diagnosis was based on his- tory, imaging study findings, visualiza- lion at surgery, and/or postmortem examination, Patients with aortic dis- ruption secondary to trauma were cluded, Data Collection A questionnaire of 200 variables, de- fined according to standard defint- tions, including demographics, his tory, physical findings, management, imaging studies, and outcomes, was de veloped by IRAD investigators.” Data were collected at presentation or by physician review of hospital records and ‘were forwarded to the IRAD Coordi- nating Center at The University of Michigan. Forms were reviewed for clinical face validity and analytical in- ternal validity. External validation was performed through a random (5%) field selection and error audit. More than 33% of patient report forms were r reviewed for validation by each site Data Analysis Data analysis was performed using sta- Uistical analysis software. Univariate analyses were used to compare fre- quency, proportion, or distribution of demographic and comorbidity vat ables between samples. x? Cross- tabulations, (tests, oF nonparametric Wilcoxon rank sum tests were applied as appropriate. To determine a trend across groups, regardless of condi- lion, the extended Mantel-Haenszel cor- relation statistic at 1 df was used. Cat- egorical modeling was used to test statistical trends and associations us- ing the likelihood ratio test for model determination. Models were selected s- ing likelihood ratio tests, with a sig- nificance level of 05. Corrections due to muluiple comparisons were used to determine appropriate levels of signii- RESULTS Demographics As of December 31, 1998, 464 pa- tients have been enrolled (TABLE 1). Two thirds of those patients were male. Mean age of ll patients was 63.1 years (05% confidence interval, 61.8-64.4 years). Type A dissection was identi- lied in 62.3% of patients, Patients with lype Bdissection were, on average, older (P<.001).A history ofcardiae surgery ‘was present in 83 patients (17.0%). lat- rogenic dissection was reported in 20 patients (4.3%). Sixty percentof patients iniully presented to an outside hospi- tal and were referred to IRAD centers (©2000 American Medical Association, All rights reserved.for continued management. A history ‘of hypertension was elicited in 72.1% of all patients. Marfan syndrome was present in 4.0% of all patients (mean age, 36 years; range, 13-52 years). Presenting Symptoms and Signs Severe pain was the most common pre: senting symptom, and 84.8% of pa- tients recalled abrupt onset (TABLE 2). The majority of patients complained of chest pain (72.7%). Anterior chest pain ‘was typical in patients with type A dis- section, whereas patients with type B dissection more often experienced pain in the back and abdomen, although there was substantial overlap (P*<.001). Of note, pain was deseribed as sharp more often than tearing oF ripping, Hy pertension at initial presentation was more common among patients with type B dissection (70.1% vs 35.7%, P<.001). One in 4 patients with type A dissection had an initial systolic blood pressure below 100 mm Hg. When ‘NEW INSIGHTS INTO ACUTE AORTIC DESECTION documented, a pulse deficit was noted ‘more often in patients with type A dis- section (P = 006). Most patients who presented with stroke also gave a his- tory of pain. Among patients with type A dissection, 12.7% presented with syn- cope, and most did not have other new rological findings. Initial Investigations Chest radiography showed absence of mediastinal widening in 37.4% of pa tients with type A dissection and an ab- normal aortic contour was noted in the minority of those patients (TABLE 3). Chest radiography showed both ab- sence of mediastinal widening and ab- sence of abnormal aortic contour in 21.3% of all patients. No chest radiog- raphy abnormality was noted in 12.4% of patients. The 12-lead electrocardio- gram most frequently showed nonspe- tic abnormalities; results were normal for 31.3% of patients, Diagnostic Imaging Most patients had multiple imaging studies performed (Table 3). Com- puted tomography was more often the initial study tool, particularly in pa lients with type B dissection, Aortog- raphy and magnetic resonance imag- ing were rarely used initially. Aor ney was noted by imaging in half of patients with type A dissection, Intramural hematoma was noted in 46 patients and two thirds ofthese had type B dissection (P<001). insulh ‘Management and Outcomes (Of 289 patients with type A dissee- tion, 72% were managed surgically (TABLE 4). Surgery was not performed in 28% of patients with type A dissec tion because of advanced age, comor- bidity, patient refusal, intramural he matoma, and death prior to planned. surgery. Surgleal therapies in ascend- ing aortic dissection included coro- ‘Table 1. Demographics and Fistor of Patents (We 464) Wah Acske Aare Desacton™ Type No.) Typ Wa) ao Category Not) ‘n= 20) ne 15) Typeavee Daragapres ‘ge. rman SO). 631 (149) e124) £63132) <.001 Ha sax 305 65.3 TEE 721 69.) a Fatored fom pay ate FAD oo aD 3 TBI 705 689) a “ 97 2.9) 205 (84.4) 1821805) i 7aiia8) Tih - ter S20) Patartpator ‘Maton ioe 22/809 (4.9 atta oe iperenson rae2 (2. Tere te ‘erosive ares Tra =A0T Rrra ae a9 (6.7) BB 22) oe Por ace desacon ASHE Tea) oo Tabet mat ESI THe 2 Frorcardac argv Bre wie erent 7 Feria repcarrt Bara Bah TEBE) Bia) 6 Tori aneunym andor dasacton aaa 2072) Bra) 2 Goreng ater Eyrass ak Sue raraee 3 Ta) 30 2 iva srgey aaa oy Tam 20H i iifogene 201) Tae) Bea a Caetaaten TR Taasa 2 Bir Sea) i Gai sro vasa 2 2) 708 iy (©2000 American Medical Association, All rights reserved, Downloaded From: on 07/04/2018 JAMA, Febury 16,2000 283, No.7 899°NEW INSIGHTS INTO ACUTE AORTIC DISSECTION ‘Table 2, Precenting Symptoms an Payseal Examination of ravente Wi Acute Rome Disecton (We 404)" Present, No, Bae, Category oportod Type A No.6) Type 8 No.) Type AEB Peay pan fepored 4421464 (05.5 an 172963 2 ‘Abupt onset STOVAAT (8) 2a s Ghost pa aV455 72.7 22 oot ‘ntoice chest pa 262690 (60.9) 191 Tea ‘0 Posteror chest pan TaaraTa So) 3 Baa m Eackpan PEST EIA Tas TT 6a oT edomral pam Tae UB) aa THe Oar ‘Seorty of pan: sanee oT HORT Oe EZ OO) Bit 735,007 Ta ‘ay of par share TARTO GEA) 705 Wa ‘Guay of pare tearing or FBT TaB267 08) 73 Ta Fadatng TaTTaaa BS 75 ar igang TATaa6 FEB) a 2 Sircope area ay = oc Pipes eariraioy as 2 221 49.0) oo SEP TOO. mn 5) Tia o Fypotensve SEP 7 oy Shock or tarpenad Bea EW ‘Rises murmur of sorte rauflcendy Tarra a Tr iar Pus dee UEST TS. 3a oy ‘Tetroraecar aon BaTeaT 77 a ‘Gongs hear Tare area 66) 2 a Table 3. Chest Radiography, Eectrocardiography, and Inial Diagnostic Imaging Results for Patients With Acute Aortic Dissection” Present, No. Reported Value, Category i ‘Type A, No. (4) Type 8, No. (4) TypeAves Faiogeaphy tongs r= 27 roo 25 8) Tara ‘No abnorrates rated Baia) aT Zea Te Fence of ered eR wes TET Were of ened mecasinorh TTA Tam Ee 7 “Revonral acre conto BI 12a Ec 2 ‘Rovomal cardiac contour TOA aa ao a Diplacorenventticaton of aria Coa Ea aie) 5 Prewalaiaion wa ra Bere 2a Eicrocardogran traige f= aa ‘No abnormal ated 10018) 85 64122.) 26 ‘Nonspeatic ST-segment or ave Grae Tea aa) 78 eae 8 Tattvantredarrypartophy 176 28.1 ar eA i ‘sehen CAE a7 201182) 2 Myocardal nacton, od O waves SA. 3 15199), 20 Myocaral infarction new Q waves 14732), 73 TO 2 or ST sogmnts Ftarmodatty m= 453 ‘Computed lomography 27761.) 145, 122 (75.4) Echocardiogram (EE andlor 15 a5 22.0) 122 25 (149) Rotoraphy Zea) % EE Magnet resonance maging aire Zi Baa) ‘ages performed per patent, mean SO) Tes eay TBE PE 900 JAMA, February 16,2000 283, No.7 Downloaded From: on 07/04/2018 (©2000 American Medical Association, All rights reserved.nary artery bypass in 33 patients, aor~ lic valve repair/replacement in 34 patients, and aortic arch repair in 39 pa- tients (21 partial; 18 complete). OF175 patients with ype Bdissection, 20% un derwent surgical therapy. Pereutane- fous fenestration and/or stenting was performed in 20 patients (4.3%). Me- dian hospital stay among surviving pa- tients was 16 days and did not differ be- twveen dissection types (P = 19). ‘Overall in-hospital mortality was 27-49%. Highest mortality occurred in pa Uients with type A dissection not rec ing surgery (58.0%), in contrast to sur~ gleally treated patients with type A dissection (26%). Patients with type B dissection treated medically had the low- est mortality (10.7%). However, mor- tality for patients with type B disse: tion who underwent surgery was 31.4%, Mortality was highest within the first 7 days of presentation (FIGURE). When re- ported, the most common causes of death among patients with type A dis- section were aortie rupture or cardiac tamponade (41.6%) and visceral ische- mia (13.9%). Aorticrupture (38.5%) and, visceral ischemia (15.4%) were the most ‘common causes of death in patients with lype B dissection, Female patients tended to be older (67.9 vs 60.6 years, P<.001) and had. a higher mortality rate than males (33.5% vs 24.19%, P<.001), Patients with intramural hematoma had mor- tality rates similar to those with inti mal tears. Among 46 patients (10% of total sample) with intramural hema- toma, 17 were type A and 29 type B. Among type A patients, 9 received sur- geal therapy, of whom 4 died, and 8 received medical therapy, of whom 4 died, Of ype B patients, 24 were man- aged medically resulting in 4 hospital deaths, and 5 required surgery, result- ing in 1 death. ‘COMMENT Acute aortic dissection may be uncom- mon, but complications occur often and carly, and the outcome is frequently fa- tal! Since dissection is a dynamic process that may occur anywhere ‘within the aorta, the clinical spectrum ‘NEW INSIGHTS INTO ACUTE AORTIC DESECTION ‘Table 4: Management and Outcomes of Acute Aotle Disecton ie infosptar moray To of presentation is broad. Symptoms may ‘mimic more common disorders such as myocardial ischemia or stroke, and physical findings may be absent or sug- gestive of adiverse range of other con- ditions.°°* Therefore, dissection is often difficult to diagnose, and a high clinical index of suspicion is manda- tory. As recently asadecadeago, alarge relerral center reported on a series of patients in whom the diagnosis was fre- quently missed on initial evaluation G8%) and first established in 28% of patients at postmortem examina tion.” Although clinicians today are better equipped to deal with the com- plex threat posed by aortic dissection, ‘mortality rates remain high. TThe typical patient in the IRAD reg {sry is a male in his seventh decade with a history of hypertension who presents with abrupt onset of chest pain. A history of hypertension, which fs considered the most common pre disposing factor for aortic dissection, was present in more than 70% of patients." In contrast to classic teaching, tear- ing or ripping were not the character- {stie descriptors of pain, While most cli- nicians would appropriately associate these terms with aortic dissection, our patients were more likely to deseribe their pain as sharp in nature. Migea- tory pain has been described as char- acteristic but was noted in only 16% of patients in IRAD." Syncope occurred in more than 12%6 of patients with type A dissection, and 10 (2.2%) ofthese patients did not have pain of other neurological findings. Thus, aortic dissection should be con- sidered in the differential diagnosis of syncope, even in the absence of pain, While the physical examination may (©2000 American Medical Association, All rights reserved, Downloaded From: on 07/04/2018 TOT BATT TypeB Ra martes NO.) Sorgical 30) TT Figure. Thity-Day Moray by Dissection ‘Type and Management Be ' VT OT SUSE S PPT PED Seetooinatto Table or desipions type Rand ‘ype sectors. provide valuable clues to the diagno- sis of aortic dissection, typical signs ‘were often absent. For example, pulse deficit, which was reported previ- ‘ously in up to 50% of patients with type A dissection, was recorded in less than 20% of patients in IRAD. The murmur of aortic regurgitation, reported previ- ‘ously in approximately wo thirds of pa- tients, was documented in 44% of pa tients with type A dissection.””" Earlier studies describe the value of the abnormal chest radiography find- ings in the evaluation of suspected aor- lic dissection.**" While chest radiog- raphy may be helpful, a substantial number of patients did not have evi- dence of widened mediastinum or ab- normal aortic contour, The incidence of aortic dissection has been estimated at from 5 to 30 per 1 million people per year, and the incl- dence of acute myocardial infaretion in the United States has been estimated at JAMA, Febuary 16,2000 Vol 283, No.7 904NEW INSIGHTS INTO ACUTE AORTIC DISSECTION +4400 per 1 million per year." Di Ferentiating aortic dissection from myo- cardial ischemia is a common clinical dilemma, and because the therapeutic strategy is very dissimilar, rapid, accu- rate diagnosis is essential") Ocea sionally, dissection and myocardial in- faretion may occur concomitantly Normal electrocardiogeam findings hhave been touted as a marker to move clinicians away from a diagnosis of myocardial ischemia or infarction and, toward dissection.”""” Normal electro- cardiogram findings were present in less than a third of our patients, suggest ing that this test was not especially help- ful in the differential diagnosis, The choice of initial imaging modal- lty may reflect availability rather than preference. Although transesophageal ‘echocardiography is accurate and ean be performed quickly at the bedside with, minimal risk, computed tomography ‘was the most common initial assess- ment performed. Despite re ports of high sensitivity and specificity fof magnetic resonance imaging, iL was rarely used asa first diagnostic imaging method.*** Availability, ime delay, re stricted ability to monitor patients dur- ing imaging, and incompaubility with implanted metal devices are likely ex planations for its limited use. Aortogrs- phy, previously the criterion standard, ‘was used infrequently, and rarely asthe iniil study. Despite improved diagnostic and. therapeutic techniques, overall in- hospital mortality for acute aortic dis- section Was 27.4%, As expected, high- est mortality occurred early after symptom onset, emphasizing the ur- gency of diagnosis and institution of ap- propriate therapy. A minority of pa tients with type A dissection did not receive surgery, primarily because of ad vanced age and comorbidity. Accord- ingly, these patients had the poorest ‘outcome, with more than half dying in the hospital, Patients with type B dis- section who underwent surgery also hhad a high mortality rate, mainly be- ‘cause of aortic rupture and complica- tions of visceral ischemia, The major- ity of patients with type B dissection had 902 JAMA, February 16,2000 253, No.7 Downloaded From: on 07/04/2018 aan uneventful hospital course and were managed medically. Patients with in- ramural hematoma had similar out- come to those with classie dissection. While the IRAD experience is the largest study of aortic dissection in re- cent ye high-volume referral sites were se- lected, the data may not be applicable to the general community. Most pa- dents were white. Many patients with aortic dissection die before presenta- tion to the hospital or prior to diagno- sis, We studied only patients who were alive at the time of diagnosis. Since some data were gathered by chart re- view, the limitations of these methods apply. However, data were rigorously reviewed, and we did not impute for any missing variables, The diagnosis re- mains unconfirmed by surgical or pathologic correlation in medically managed survivors, However, because patients were evaluated at referral cen- {ers and had presentations and imag- ing studies consistent with acute dis- section, we do not believe that this isa significant limitation. While the out- come data are striking, inferences should be made with eaution, Patient survival to hospitalization varies, and the choice of therapy was influenced by many factors, including age and con- dition of the patient 5, there are limitations. Since CONCLUSIONS Acute aortic dissection is uncommon, but complications develop rapidly and the outcome is often fatal. The typical presentation is characterized by acute onset of severe pain. However, clini- cal manifestationsare diverse, and what were previously considered to be clas- sic symptoms and signs are often ab- sent. Therefore, a high clinical index of suspicion is necessary Despite significant advances in di- agnostic and therapeutic techniques, morbidity and mortality rates remain high. Although itis clear that during the past 2 centuries much progress has been made, these data support the need for continued improvements in our abil- lty to understand, diagnose, and man- age this devastating condition, eR 4. Leonard JC. Tomas Beil Peacock and he exy Risory of essecing aneurysm. Bi! 1979;2260 dee 2 hemo U. The Hitry of Cardiology. New Yor ‘ive Parhenon Pushing Grou, 1958 5 Hist A Johns, Kane 9). Diseeng aneurysm Oi theaori a review of 505 czas Madione 158 Saran, 4, Warden, Coben M, Read RC. Contd rose ticalitoneropen racic surge! Thorac. SSotpeaat ats 5 Dedakey Mi, CoceyD, CeeehO Surgical or Sderatons of ssc aneurysm of he sa. Aan Sug 1958; 142 886-612, Svan 5, Cana W, Forester J, Marcus Dix ‘ond G, Chante D.Cateteraation ofthe hatin ‘manvethureot a low-drecedballoge ipa cat ler Mag) Med 1970S 7481 7- Giese Ra, Stson 8, Hat gsvorh F, Buehler DB. reshetteplcement of these arch J Thorac (Gartovase Surg. 1975:70:1081-1053. 8 Bavara ie oo ¥, Hal RA, Carpenter, Grd ner Retrograce cerebral ard dtl sore peru Son ding ascending and thracoabdominal sric pert Aan Thoac Sug 1995 50:345 52, 3° Boggs 8, Torhana DF, Gefin GA eta. Opt nal myocrdalpesenation wih an acaleemic ey Uleigeurdelegesouton )Tavac Cacovasc Sr. ser s3a3e 86 10. Kovshoukos NT DougeisD Surgery thetho ‘ace ata Nel J Med 1997336 15761888. {7 Fann Sit JA Miler DC ea Sugeal mar {gimentof ore dscecton during 230 poi Gatton 195 308 supa 13121 {2 Ramer. lod edplegia: are ar com Daizonontheystatd cadences Ann Tore Sur. {sorszasi36r 13, Wheat, PaerR Bary Te Treatment of dssecting aneurysms ofthe ata without su $2.1 Thorac Caovasc Surg. 196550 368-373, Je alte We, Moran If. The evliion of redial nd sugeal management of acute src dsecton Glealabon. 197754 pt 1503-505 45. Wits OM, Boer TE, Mesa LM. Rel of ‘mesenteric ichema in ype lari dissection with Derstaneousfenetaton ofthe sorte spt, Ra olay 1990; 174 350<452 46. Waiter Pl, Dake MD Michel RS, Miler DC. The Us of endovascuarteciques forthe eaten of ompleatons of sore deze. Vase Sur 1293 ‘toe 105 47. Chavan A Hausmann D, Order C a. nts ‘slur utasound-gaded percutaneous fenestra ton of te tinal ap inthe asec aorta, Cree lation 19979621242027, ‘8, Dake MD, Kato, Nithel RS, al Engovs- Car ster-grat puceren! forthe eat acute Soe asecin. IV Engl J Med, 1999;340:1586 130 4B. henaber CA, FatorR Lund , el Nong Caleconsaconf tore sor secon by et fiat lacement.N Eng) / Med. 1999:300°1539 fa, 20. Cigar, sbacer EM, DeSantis RW, age fA Diagnostic imaging Inthe evaluation of ss ied aot dstecton ald standards and new a. Fctons N ng)! ied 19,32830-18 2. Godin 1b, Herne R, Solera CO Fed ‘teIMP, Upton Evin of esectons and a inns of tetova aera cowertendl anda fame Cl searing. Railay. 1980196125133 22" Bball Engberg, Datel W, Rotana Vi Sec; Renal Eenecarographyndagoss of Sorc astecton Lancet. 1988 f457-46 250 Hamad’ Talay, Kimura, la, Ne iia Nato Type A aoe asecon:evauston thats CT. Rasa. 1992: 185 185-58 (©2000 American Medical Association, All rights reserved.24. Nenabr CA Speimann RP, von Kodoltsch al Dragos of horace sore assedton. mag” het esonance maging verustranssephagea eo (eadogaphy. Creation. 198.35 488-447 25. Menaber CA. von Kodoisch, Nels Vt {he aignoss of heaoe sore secon by non vasve agg procedure M ng) Med 953 328: 13 26. Kandhara 8. Ao section the a on fe ledtonl. Cirulation 1985387:1765-1768. 27, Prete, Von Segese LK Aor secon. Lar el War oder EL 28. Roberts C3, Rebars WC. Aattc dissection wth fhe entrance tear nthe descending tora sort ‘talysof necropsy patients. Ann Surg. 1994.23 Sbece, 28, fckestaff LK Paleo PC, Holer Lett Tho racic aorc anurans: population-based sty. Su fey 19ens2 1103-1108. $0” O'Gara Pr, Desancts RW. Acute atc ae fon and teva fwd a common agnosia therapeutic approach fedora). Ciealation. 1995; shisreta7e 531. Nenabr CA, von KdollschY, Petersen Bel intamural Removage ofthe race srt dag ‘osc and therapeutic peas. Cicultion. 1996 Saaaatar2 532. Vamada Tad, Harada) ert econ wth ut imal upture:dagness with MR maging and (CF Rattogy 988168387 352, ‘NEW INSIGHTS INTO ACUTE AORTIC DESECTION 2. Roberts NC. otic secon: anatomy, conse (ques, andcauses A Heat) 198101198 214 Sa Eagle WA, DeSants RW. Aotte dissection. Cur Pro Card, 989"14.225.278 35, Larson EW, Edwards WD. Rk factors for are ‘Sizes a necropsy sud of 161 cases Ca Got 984 33889.825 36. Daly PO, Tebiood HW, Stason 8, Wuerein RD, Shuraay NE Management of acu aor ds secons An Tova Surg 1970,10237-247, 57. Spt PC ste IA, Joye et a. Clea {ectues and diferent dagnoss of aor dsc ‘on-expenence wth 236 cass (980 bough 190) ‘Maye Cin Pec 199568642-651 3H Eage(A QurlermousT, Kitzer GA. etal Spec ‘eumot condiionsintay suggesting acute ade ds. Seon but with negative aoogans. Ar J Cada ‘sag57322-205 38 National Carcovasuar Data Regi. Amer {an Cotege of Caobogy Web ste. avaiable at itp: waraccorglogevindex tat Acesed De ‘aber 29,1995 40. Chil F, Marcie MC, Anil L, eal, Out ‘ame of 90 patie wih aati asecton 2 12yex) Multene erence ur Peat 199011311319. {A Jameson WR Muro Al, Moaginima RT, Alen Priyer GF Caren AN. Aor dsecton eat ag not and sual management are te ey os ‘al Can I Surg. 198225:15.189, {2 Svenon LG, rawr 5, Hes WR, Cosel, Saf isco ofthe sorta ana deting src ‘steuysms moron ea along sural dts Celaton, TOE supple 13. Baers Varudmaniestatons of eet neu of the sta, ANIA 1956 161 685-692 1 Amatong We, Sach DS Carey LM, Foe, {ova Mt, Katroon EA, Clea and eehocaro {aah fadingsn pubes wth susperted acuta. Aicdisecion im Heart) 1938 13610511060, 45. Lnasay ir Hurst Creal atures and pos hows asecting aneurysm of the srt: ae {ppratal Creation, 1967 35890-058 18. ison Sk Hutehine Gt Rote ecg an furan cause facorsin 20 cube Ach Patol ab Mec. 1962 106:175- 180 4 Sater EE DeSantis RW. The cll ecogron of dsecing aric aneurysm. Am Med. 1976360: ees 8. Eamest IV, Mt JR Shay PI Roentgen {gaphe inangs interac sorb assecion. ay Clo Bron s97sat3-50, 49, Amencan Heart Asacaton. 1998 Heart and Sioie tatsteal Update Daas, Tox American Heat Derocaton: 1998 50. sankersnp IC Almauist AK. Caovasuar com Dletons of thrombi erapy in parts with 3 Iistaken diagnose of sate myocardial infarction Tam Cl Car 989-14-1579-1582. Bi. Buber) Daves AH, Westby 5. steptakinase in Seite sorte dcecton, 2M, 1900°300317-519, Disease is very old, and nothing about ithas changed. It is we who change, as we learn to recognize what \was formerly imperceptible. "—Jean Martin Charcot (1825-1803) (©2000 American Medical Association, All rights reserved, Downloaded From: on 07/04/2018 JAMA, Fbnuaty 16, 2000-61283, No.7 908