DISSECTIONS OF AORTA

Overview
 Blood passes through the tear into the
aortic media, separating the media from
the intima and creating a false lumen
 Peak incidence is in the sixth to seventh
decade
 Men are affected twice as commonly as
women
 When left untreated…
– 33% of patients die within the first 24
hours
– 50% die within 48 hours
– ~75% die within 2-weeks
 Mechanism
 Primary event is a tear in
the aortic intima
 Blood enters the wall of
the artery, as a
hematoma dissecting
between its layers.
 Formation of a blood-filled
channel within the aortic
wall
 Propagation of the
dissection can occur both
Adventita
distal and proximal to the Media
initial tear intima
 Predisposing factors
 Long standing history of hypertension
– 80% of cases have co-existing HTN
 Collagen disorders
– Marfan syndrome (6-9% of aortic dissections)
 Iatrogenic (cardiac cath, cardiac
surgery)
 Pregnancy
 Coarctation of aorta
 Types
 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
TYPES OF AORTIC DISSECTION
 Complications of dissection:

ischemia (coronary, cerebral, spinal, or

visceral)

aortic regurgitation

cardiac tamponade
 Clinical Features

 Abrupt onset of severe, sharp or "tearing"

posterior chest or back pain

 Pulse deficit
– weak/absent carotid, brachial, or femoral
pulse resulting from compression by
hematoma
 Diagnosis
 acute aortic dissections could be identified
based upon some combination of the
following:
1. Abrupt onset of thoracic or abdominal
pain with a sharp, tearing and/or ripping
character
2. Mediastinal and/or aortic widening on
chest radiograph
3. A variation in pulse (absence of a
proximal extremity or carotid pulse)
and/or blood pressure (>20 mmHg
difference between the right and left
arm)
 Diagnostic Tests
 Transesophageal echocardiogram

 Specificity 95%

 Advantages

– Close proximity of the esophagus to the thoracic aorta

– Portable procedure
– Yields diagnosis in < 5 minutes
– Useful in patients too unstable for MRI
– True and false lumens can be identified
– Thrombosis, pericardial effusion, and proximal coronary
arteries can be readily visualized
 Diagnostic Tests
 EKG
– Absence of EKG changes usually helps
distinguish dissection from angina
– Usually non-specific ST-T wave changes seen

 CXR
– May show widening of the aorta with ascending
aorta dissections
 Medical therapy
 Reduce systolic BP to 100 to 110 mmHg or the lowest level
that is tolerated

 Beta blockers
– Propanolol
– Labetalol

 If SBP remains >100mmHg, nitroprusside should be added

 Surgery -- prevents medial extension reaching the

pericardium and producing fatal tamponade or worsening
other complications