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AORTIC DISSECTION

Aortic Dissection

Background Epidemiology Clinical characteristics Diagnostic Modalities Treatment

History

First known case was King George II on October, 25, 1760 First successful repair by Dr. Michael DeBakey in 1955. ". . . spontaneous tear of the arterial coats is associated with atrocious pain, with symptoms, indeed, in the case of the aorta of angina pectoris and many instances have been mistaken for it"
Osler, 1910.

William

Mechanism

Primary event is a tear in the aortic intima. Degeneration of aortic media, or cystic medial necrosis, is felt to be a prerequisite nontraumatic aortic dissection Blood passes into the aortic media through the tear, separating the intima from the media and creating a false lumen. Uncertain whether the initiating event is a primary rupture of the intima with secondary dissection of the media, or hemorrhage within the media and subsequent rupture of the overlying intima

Mechanism

Propagation of the dissection can occur both distal and proximal to the initial tear, Complications of dissection:
ischemia

(coronary, cerebral, spinal, or visceral) aortic regurgitation Pericardial effusion/cardiac tamponade

Nomenclature
DeBakey classification system Type I - Originates in ascending aorta, propagates at least to the aortic arch and often beyond it distally. Type II Originates in and is confined to the ascending aorta. Type III Originates in descending aorta, rarely extends proximally but will extend distally. Daily (Stanford) classification system Divided into 2 groups; A and B depending on whether the ascending aorta is involved. A = Type I and II DeBakey B = Type III DeBakey

Percentage Type

60%

10-15%

25-30% DeBakey III Stanford B Distal

DeBakey I DeBakey II Stanford A Proximal

Classification of aortic dissection

Incidence

Ranges from 2-10 per 100,000 person-years Evidence of dissection is found in 1-3% of all autopsies

Whos affected?

International Registry of Acute Aortic Dissection (IRAD)

65%

men mean age 63yrs Women tend to present older (67 vs. 60yrs)

Highest incidence in patients 50 to 70 years old. Male-to-female ratio 2:1 Half of dissections in females before age 40 occur during pregnancy

Mortality

When left untreated


33%

of patients die within the first 24 hours 50% die within 48 hours ~75% die within 2-weeks

Aortic dissection mimickers


Myocardial

ischemia due to an acute coronary syndrome with or without ST segment elevation Pericarditis Pulmonary embolus Aortic regurgitation without dissection Aortic aneurysm without dissection Musculoskeletal pain Mediastinal tumors Pleuritis Cholecystitis Atherosclerotic or cholesterol embolism Peptic ulcer disease or perforating ulcer Acute pancreatitis

Predisposing factors

Older patients

Younger patients

HTN (72% of IRAD patients) Pre-existing aneurysm (13%) Inflammatory disease (giant cell, takayasu, RA, syphilitic aortitis) Collagen disorders (Marfans [50% of pts <40], Ehlers-Danlos, Pseudoxanthoma elasticum Coarctation (Turners syndrome) Family history (up to 19% of pts, # of mutations identified) Bicuspid aortic valve Trauma/Iatrogenic Crack cocaine, (37% in largely AA, inner-city population study)
mean

duration from last cocaine use ~12 hours. Mechanism may be abrupt, transient hypertension due to catecholamine release.

Aortic Dissection

Background Epidemiology Clinical characteristics Diagnostic Modalities Treatment

History

Sudden onset of severe sharp chest pain Pain location may indicate where dissection arises
Anterior chest pain >> aortic arch/aortic root Neck or jaw pain >> aortic arch to the great vessels

Physical Examination

Hypertension Hypotension or shock Pulse deficit Interarm BP difference >20mmHg Signs of aortic regurgitation Pulmonary edema

Physical Examination

Cardiac temponade Acute MI Pericarditis Neurologic deficits Visceral organ infarction Compressive complications

Aortic Dissection

Background Epidemiology Clinical characteristics Diagnostic Modalities Treatment

Radiologic Investigation

Chest x-ray CT scanning MRI Echocardiography

Chest x-ray

Pros:

Initial W/U c bedside availiability May or may not reveal abnormalities

Cons:

Classic finding: Widening mediastinum

CT scanning

CTA with 3Dreconstruction: definite diagnotic test Cons:


Only in hemodynamically stable Pt. IV contrast agents adverse effects

Allergy Contrast-induced nephropathy

MRI

Pros:

Sensitivity and specificity 98% No contrast medium and ionizing radiation


Only in hemodynamically stable Pt. Not ready availability Require long duration Contraindication with pacemaker

Cons:

Echocardiography

Transesophageal > Transthoracic Pros:

ideal for hemodynamic instability Noninvasive quick study Diagnosing cardiac temponade and aortic regurgitation

Cons: limitted visualized view

Aortic Dissection

Background Epidemiology Clinical characteristics Diagnostic Modalities Treatment

Medical management

Untreated aortic dissection or intramural hematoma Basic management Surgery -- prevents medial extension reaching the pericardium and producing fatal tamponade or worsening other complications

25%

die within 24hrs 50% by 48hrs


Type

A dissection surgery Type B dissection medical management

Pre-OR management

Virtually all non-shocked patients require medical management prior to surgery Aim of medical management:
reduce

the absolute pressure on the damaged aortic media Reduce the rate of rise of that pressure (dP/dT).

Medical management

Blood pressure control Blood pressure control Blood pressure control Pain control

Main goals of medical management

Systolic BP < 100 mmHg. Pain free. Adequate renal perfusion (urine output > 30 ml/hr). No evidence of cerebral hypoperfusion. Minimized shear stress (-blocked to < 55/min).

Antihypertensive choice

Labetalol for beta blockade Nitroprusside if HR controlled but SBP still >100mmHg

Antihypertensive choice

Start with -blockers use of a vasodilator in isolation will actually increase aortic shear stress by widening the pulse pressure and the dP/dT of left ventricular ejection.

Which arm to measure?

Blood pressure should be measured in the arm with the highest reading.